Self-critical perfectionism, daily emotional reactivity, and psychosocial
maladjustment: Three multi-wave longitudinal studies
Tobey Mandel, Department of Psychology
McGill University
Montreal, Quebec
April 2016
A thesis submitted to McGill University in partial fulfillment of the requirements of the degree
of Doctorate of Philosophy
© Tobey Mandel 2016
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Table of Contents
Abstract..............................................................................................................iii
Résumé...............................................................................................................vi
Acknowledgments..............................................................................................ix
Contribution of Authors.....................................................................................xi
Statement of Original Contribution...................................................................xii
General Introduction..........................................................................................1
Article 1.............................................................................................................18
Bridge to Article 2.............................................................................................68
Article 2.............................................................................................................69
Bridge to Article 3.............................................................................................110
Article 3.............................................................................................................111
General Discussion...........................................................................................148
General References...........................................................................................162
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Abstract
Self-critical (SC) perfectionism, the more maladaptive dimension of perfectionism, has
been associated with depression, anxiety, stress and various other difficulties (Békés et al. 2015;
Dunkley, Zuroff & Blankstein, 2003; Sherry, Nealis, Macneil, Stewart, Sherry, & Smith, 2013).
In addition, SC perfectionism has been shown to interfere with the effectiveness of treatment
aiming to address these psychosocial difficulties (see Blatt & Zuroff, 2005; Kannan & Lewitt,
2013). The overall purpose of the current doctoral thesis was to identify important explanatory
mechanisms that help to clarify the relationship between SC perfectionism and negative
outcomes over time in both community as well as clinical samples with the goal of identifying
important targets for future interventions. More specifically, the goal of my dissertation was to
examine the role of emotional reactivity (i.e. daily fluctuations in negative mood in response to
daily fluctuations in stress appraisals) as an important explanatory variable in the relationship
between SC perfectionism and psychosocial maladjustment.
Article 1 examined the role of heightened stress reactivity (daily increases in negative
mood in response to increases in daily stress) in a sample of 150 community adults in the
relationship between SC perfectionism and depressive and anxious symptoms over a period of
four years. In order to measure stress reactivity, daily dairies measuring daily stress and affect
(e.g., sadness, negative affect) for 14 consecutive days were collected at both Month 6 and Year
3. Results demonstrated that SC perfectionism predicted daily stress–sadness reactivity (i.e.,
greater increases in sadness in response to increases in stress) across Month 6 and Year 3, which
in turn mediated the relationship between higher SC perfectionism and general depressive and
anxious symptoms and anhedonic depressive symptoms four years later, controlling for baseline
symptoms. Article 2 examined the role of heightened interpersonal sensitivity (daily increases in
iv
negative mood in response to increases in negative social interactions) in a sample of 145
community adults in the relationship between SC perfectionism and interpersonal stress
generation four years later. Interpersonal sensitivity was measured at both Month 6 and Year 3
using 14 days of daily diaries measuring daily negative interpersonal interactions and affect.
Findings showed that interpersonal-sadness sensitivity (i.e., greater increases in daily sadness in
response to increases in daily negative social interactions) mediated the relationship between SC
perfectionism and interpersonal stress generation four years later, controlling for the effects of
depressive symptoms. In both Articles 1 and 2, daily reactivity to stress with sadness, compared
to daily reactivity to stress with negative affect (NA), more consistently mediated the
relationship between SC perfectionism and negative outcomes. This demonstrated the especially
maladaptive nature of responding to stress appraisals with sadness as opposed to broader
negative affect. Furthermore, mean levels of daily stress/negative social interactions did not
explain the relationship between SC perfectionism and negative outcomes, demonstrating that
how one responds to an event, as opposed to the event itself, may be especially problematic for
individuals with higher SC perfectionism over time.
Article 3 evaluated whether stress-sadness reactivity and cortisol activity moderated the
relationship between SC perfectionism and depressive symptoms in a sample of 43 depressed
patients over a one-year period. Stress-sadness reactivity was measured using seven days of daily
dairies examining daily stress and affect. Salivary cortisol was collected on two separate days.
High levels of SC perfectionism in combination with high levels of both daily stress-sadness
reactivity and the cortisol awakening response (CAR) predicted less depression improvement
relative to other patients one year later. Low SC perfectionism in combination with higher levels
of stress-sadness reactivity/CAR predicted the lowest levels of depression over time.
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Taken together, the empirical findings from the current thesis demonstrate that emotional
reactivity serves as an important explanatory variable in the relationship between SC
perfectionism and a host of negative outcomes. By extension, these findings highlight that
emotional reactivity may serve as an important target for future interventions for SC
perfectionistic individuals who are typically resistant to treatment. In addition, results from the
current dissertation suggest that targeting dysfunctional self-critical characteristics that intensify
the impact of heightened stress-sadness reactivity and the CAR may be beneficial when treating
depressed individuals with higher SC perfectionism.
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Résumé
Le perfectionnisme autocritique, la dimension plus inadapté du perfectionnisme, a été
associée à la dépression, à l’anxiété, au stress et à diverses autres difficultés (Békés et al. 2015;
Dunkley, Zuroff & Blankstein, 2003; Sherry, Nealis, Macneil, Stewart, Sherry, & Smith, 2013).
De plus, il a été montré que le perfectionnisme autocritique interfère avec l’efficacité du
traitement qui vise à remédier à ces difficultés psychosociales (voir Blatt & Zuroff, 2005;
Kannan & Lewitt, 2013). L'objectif général de cette thèse de doctorat était d'identifier
d’importants mécanismes explicatifs qui aident à clarifier la relation entre le perfectionnisme
autocritique et les conséquences négatives au fil du temps auprès d’échantillons communautaires
et cliniques, dans le but d'identifier des cibles importantes pour les interventions futures. Plus
précisément, l'objectif de ma thèse était d'examiner le rôle de la réactivité émotionnelle (c’est-àdire, les fluctuations quotidiennes de l'humeur en réponse à des fluctuations quotidiennes
d’évaluations de stress) comme une importante variable explicative de la relation entre le
perfectionnisme autocritique et l'inadaptation psychosociale.
Dans un échantillon de 150 adultes de la communauté, l’Article 1 a examiné le rôle de
la réactivité accrue face au stress (c’est à dire, une augmentation quotidienne de l'humeur
négative en réponse à l'augmentation des évaluations du stress) dans la relation entre le
perfectionnisme autocritique et les symptômes dépressifs et anxieux sur une période de quatre
ans. Afin de mesurer la réactivité au stress, des journaux quotidiens mesurant le stress et l’affect
(par exemple, la tristesse et l’affect négatif) ont été collectées pendant 14 jours consécutifs au
Mois 6 et à l’Année 3. Les résultats démontraient que le perfectionnisme autocritique prédisait la
réactivité stress-tristesse quotidienne (c’est à dire, de plus grande augmentations de tristesse en
réponse à une augmentation du stress) à travers le Mois 6 et l’Année 3, laquelle agissait à son
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tour comme médiateur dans la relation entre le perfectionnisme autocritique élevé et les
symptômes général de dépression et d’anxiété, ainsi que les symptômes anhédoniques de la
dépression quatre ans plus tard, après avoir contrôlé les symptômes de base. Dans un
échantillons de 145 adultes de la communauté, l’Article 2 a examiné le rôle de la sensibilité
interpersonnelle élevée (augmentation quotidienne de l’humeur négative en réponse a une
augmentation des interactions sociales négatives) dans la relation entre le perfectionnisme
autocritique et la génération du stress interpersonnel quatre ans plus tard. La sensibilité
interpersonnelle a été mesurée au Mois 6 et à l’Année 3 en utilisant 14 jours de journaux
quotidiens mesurant les interactions interpersonnelles négatives et l’affect au quotidien. Les
résultats démontraient que la sensibilité interpersonnelle-tristesse (c’est-à-dire, de plus grandes
augmentation de tristesse en réponse à une augmentation des interactions sociales négatives)
agissait comme médiateur dans la relation entre le perfectionnisme autocritique élevée et de plus
importantes création de stress interpersonnel quatre ans plus tard, après avoir contrôlé l’effet des
symptômes dépressif. Dans les Articles 1 et 2, la réactivité quotidienne au stress avec de la
tristesse agissait comme médiateur dans la relation entre le perfectionnisme autocritique et des
conséquences négatives, et de façon plus cohérente que ne l’a faisait la réactivité quotidienne au
stress avec l’affect négatif. Ceci démontrait la nature particulièrement inadaptée de répondre aux
évaluations de stress avec la tristesse comparé à une réponse d’affect négatif plus général. De
plus, les niveaux moyens de stress/interactions sociales négatives quotidiens n’expliquaient pas
la relation entre le perfectionnisme autocritique et les conséquences négatives, ce qui démontre
que la façon de répondre à un évènement, et non l’évènement lui-même, peut s’avérer
particulièrement problématique pour les personnes présentant de plus hauts niveaux de
perfectionnisme autocritique au fil du temps.
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L’Article 3 a évalué si la réactivité stress-tristesse et l’activité cortisolique ont modéré
la relation entre le perfectionnisme autocritique et les symptômes dépressifs dans un échantillon
de 43 patients souffrant de dépression sur une durée d’un an. La réactivité stress-tristesse a été
mesurée en utilisant 7 jours de journaux quotidiens mesurant leur stress et leur affect au
quotidien. Cortisolique salivaire ont été recueillies sur deux jours distincts. Les patients ayant un
niveau élevé de perfectionnisme autocritique, combiné à un niveau élevé de réactivité stresstristesse quotidienne et à l’augmentation cortisolique au réveil, montraient moins d’amélioration
des symptômes de dépression comparé aux autres patients un an plus tard. Un niveaux plus bas
du perfectionnisme autocritique, combiné à un niveau élevé de réactivité stress-tristesse/
augmentation cortisolique au réveil, prédisait un niveau inférieur de dépression au fil du temps.
Dans l’ensemble, les résultats empiriques de cette thèse démontrent que la réactivité
émotionnelle sert d’importante variable explicative de la relation entre le perfectionnisme
autocritique et toute une série de conséquences négatives. Par extension, ces résultats soulignent
que la réactivité émotionnelle peut servir de cible importante dans les interventions futures pour
les individus présentant un perfectionnisme autocritique, lesquels répondent généralement moins
bien au traitement. En outre, les résultats de cette thèse suggèrent que le ciblage des
caractéristiques dysfonctionnelles de l'autocritique qui intensifient l'impact de la réactivité accrue
stress-tristesse et l’augmentation cortisolique au réveil peut soutenir le traitement des individus
déprimés présentant de plus hauts niveaux de perfectionnisme autocritique.
ix
Acknowledgements
This thesis would not have been made possible without the support, guidance, and
encouragement from many important individuals. Reflecting on the last six years, it is clear that
there have been exciting and challenging hurdles that I’ve faced, and overcome, in no small part
thanks to the community of professors, graduate students and friends that have helped make up
my graduate school experience.
First and foremost, I would like to thank my supervisor, Dr. David Dunkley, for playing
such a crucial role in my development as a clinical researcher. David helped me to explore and
pursue my ideas and interests, while continually providing guidance and feedback throughout my
degree. He was always available and happy to discuss ideas and directions for my thesis, and
always encouraged me to strive for my best by providing guidance while encouraging me to
explore my own conceptualization of our research. David was also instrumental in selecting
wonderful lab mates to work alongside, which helped create a collaborative, warm and inviting
lab environment.
Moreover, I would like to thank several lab mates, classmates, and friends who have
provided encouragement, support, and with whom I have made long lasting friendships that I
hope continue for many years to come. Molly Moroz, Denisa Ma, Amanda Thaw, and Shauna
Solomon-Krakus made coming to work in the lab something to look forward to. Having lab
mates with whom you can discuss research and weekend plans with, as well as our shared
appreciation for Thai food, brought my time at the Jewish General Hospital to life. I would also
like to thank Maxim Lewkowski, Jesse Metzger, and Claire Starrs, for serving as important
mentors throughout my graduate school experience. To my classmates, I feel very lucky to have
shared this experience with you all. I have learned so much from each of you, and am so proud to
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have been given the opportunity to grow alongside you throughout the last six years. I would like
to share a special thank you to Laura Cuttini and Maeve O’Leary-Barrett. You have both been
instrumental in making the last six years some of the best of my life. It has been such a pleasure
to travel this road together.
I would also like to thank David Zuroff, for taking me under his wing and providing me
with a “home base” at McGill. Being included in the Zuroff lab provided an opportunity to hear
new ideas, receive support and encouragement from thoughtful peers, and feel welcome to share
in the accomplishments and success of others in the department. Giovanna Locascio and
Chantale Bousquet, you are the most supportive, warm, and inviting administrative advisors I
could have had the pleasure of working with. In addition, I would like to thank my clinical
supervisors, who have guided my understanding of mental health, treatment, and the importance
of the therapeutic relationship. Your guidance has helped to shape me as a future clinician, and
for that I am grateful. I would like to particularly thank Irv Binik for encouraging me to use the
‘process’ of therapy to better understand clients and their reactions in everyday life. This has not
only helped guide my research, but I believe has also molded me into a more conscientious and
effective therapist.
Finally, I would like to thank my partner, Nathaniel, for providing endless support and
encouragement, for believing in me wholeheartedly, and for listening (patiently) to every detail
of my work over the last six years. I would also like to thank my family for their unconditional
love and support during this important time in my life.
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Contribution of Authors
The present doctoral thesis is comprised of three manuscripts. The first article was
published in Journal of Counseling Psychology, and was co-authored by myself, David Dunkley,
and Molly Moroz. The second article is in preparation for submission to European Journal of
Personality, and will likely be submitted in the following few weeks. Article 2 is co-authored by
myself, David Dunkley, and Claire Starrs. The data for both the first and second article were
collected by myself, Molly Moroz, Denise Ma, Jody-Lynn Berg, Angela Kyparissis, Magali
Purcell Lalonde, Ellen Stephenson, and Amber-Lee Shattler, under the supervision of David
Dunkley. For Article 2, myself, David Dunkley, Molly Moroz, and Claire Starrs were involved
in regular meetings to establish the inter-rater reliability of the contextual-threat interviews. For
both the first and second manuscript, I conducted the literature review and developed the
research questions with feedback from David Dunkley. I completed all the data analyses and
interpretations, and wrote and revised the complete manuscript with the editorial feedback of the
respective co-authors.
The third article is in preparation for submission to Psychoneuroendocrinology, and will
likely be submitted in the upcoming few weeks. Article 3 is co-authored by myself, David
Dunkley, Maxim Lewkowski, David Zuroff, Sonia Lupien, N. M. K. Ng Ying Kin, Robert-Paul
Juster, Elizabeth Foley, Gail Myhr, and Ruta Westreich. The data for the third manuscript was
collected by Maxim Lewkowski, Elizabeth Foley, Jody-Lynn Berg, and Denise Ma. I conducted
the literature review and formulated the research questions with the guidance of David Dunkley.
I completed all of the data analyses and data interpretation, with input from David Dunkley,
Sonia Lupien, and Robert-Paul Juster. Lastly, I wrote and edited the complete manuscript with
editorial feedback from the co-authors.
xii
Statement of Original Contribution
The present doctoral thesis provides several original contributions to our understanding
of the relationship between personality, emotional reactivity and negative outcomes. Research
has established that there exists a relationship between perfectionism and psychosocial
maladjustment. In addition, previous research has shown that individuals with higher SC
perfectionism are emotionally reactive to various stressors. However, research has yet to
combine these areas of research to better identify the mechanisms that explain why and under
which conditions self-critical (SC) perfectionism relates to various psychosocial difficulties over
time. The current thesis is the first to use longitudinal designs to examine the role of emotional
reactivity in the relationship between SC perfectionism and a host of negative outcomes.
Each article in the current thesis provides unique and novel contributions to the literature.
Article 1 is the first to derive and test stress reactivity slopes, which were based on the
relationship between an individual’s daily stress levels and corresponding mood, as mediators in
the relationship SC perfectionism and distress symptoms. These independent appraisal-emotion
reactivity slopes capture important information regarding an individual’s daily emotional
patterns that may place them at risk for developing difficulties over time. Further, Article 1
examines whether stress reactivity mediates the relationship between SC perfectionism and
depressive and anxious symptoms over a period of four years, which has not yet been explored in
previous research. These analyses help to identify whether stress sensitivity serves as an
important mechanism to target in future interventions.
Article 2 provides an original contribution to the literature by explicitly testing the theory
that interpersonal sensitivity explains the relationship between maladaptive perfectionism and
stress generation. Though previous research has assessed components of this theory, Article 2 is
xiii
the first to use interpersonal sensitivity slopes that represent an individual’s relationship between
daily negative social interactions and corresponding mood as independent variables in explaining
this relationship. Appraisal-emotion reactivity slopes provide a more rigorous measure of
interpersonal sensitivity, allowing for a more sophisticated test of the above theory. Furthermore,
Article 2 is the first to examine the relationship between SC perfectionism, interpersonal
sensitivity, and stress generation using a contextual-threat interview, which provides a more
detailed evaluation of various forms of stress and helps to control for memory and reporting
biases.
Articles 1 and 2 are also the first to compare emotional reactivity with sadness versus
negative affect in the relationship between SC perfectionism and psychosocial maladjustment in
an effort to establish whether responding to stress appraisals with certain emotions in particular
is especially detrimental for individuals with higher SC perfectionism. Articles 1 and 2 are also
the first to establish whether emotional reactivity remains stable over a period of 2.5 years,
which helps to clarify whether emotional reactivity serves as a particularly important target for
future interventions. Importantly, Articles 1 and 2 are also the first to examine these relationships
over a period of as long as four years, which further helps to disentangle the long-term impact of
emotional reactivity for higher SC perfectionists.
Article 3 provided a novel examination of the role of stress reactivity in the relationship
between SC perfectionism and depression in a sample of depressed outpatients by examining
stress reactivity slopes as a moderator of this relationship. This analysis clarifies under which
conditions high SC perfectionists are most at risk of maintaining depressive symptoms following
treatment. Furthermore, Article 3 is the first to examine both stress reactivity slopes as well as
two separate forms of cortisol activity in the relationship between SC perfectionism and
xiv
depression over a one-year period, which provides a greater understanding of the role of both
emotional reactivity and physiological stress processes in the maintenance of depression over
time for high SC perfectionists.
Thus, to summarize, the current thesis is the first to employ several novel methods to
assess the relationship between SC perfectionism and negative outcomes, including a multi-year
longitudinal design, multiple instances of daily diaries to provide more rigorous measures of
emotional reactivity, thorough interview measures to assess for stress generation, and tests in
both community as well as clinical samples.
1
General Introduction
“In the end, perfection is just a concept - an impossibility we use to torture ourselves and that
contradicts nature.”
―Guillermo del Toro,Cabinet of Curiosities: My Notebooks, Collections, and Other
Obsessions
“Perfectionism is the voice of the oppressor, the enemy of the people. It will keep you insane
your whole life”
― Anne Lamott, Bird By Bird – Some Instructions On Writing And Life
Those that struggle with the idea of perfection, the goal of attaining the impossible, know
best how painfully destructive this notion can be. The benefits and consequences of
perfectionism have been hotly debated, and the empirical literature on perfectionism has been
growing rapidly over the past three decades. Findings have demonstrated that perfectionism is an
important cognitive-personality factor associated with a host of negative outcomes, including
various forms of stress (Békés et al., 2015; Dunkley, Zuroff, & Blankstein, 2003), depressive and
anxious symptoms (Antony, Purdon, Huta, & Swinson, 1998; McGrath et al., 2012; Sherry et al.,
2013), eating disorders (Bardone-Cone et al., 2007), and general negative health outcomes
(Molnar, Sadava, Flett, & Colautti, 2012). The goal of the current thesis is to better understand
what factors play a role in the relationship between perfectionism and psychosocial
maladjustment over time. In order to explore this, I will first begin by describing the history of
the perfectionism constructs that will be discussed in this thesis. Following this, I will explore
the importance of the perfectionism diathesis-stress model in helping to explain the relationship
between SC perfectionism and negative outcomes. I will then introduce emotional reactivity, a
mechanism that I argue plays a key role in the relationship between perfectionism and negative
outcomes. Furthermore, I will explore the importance of biomarkers of psychosocial stress in the
relationship between perfectionism and distress. Finally, I will outline previous gaps in the
literature and describe how the current thesis seeks to fill these gaps and answer critical
2
questions concerning the relationship between perfectionism, emotional reactivity, and
psychological difficulties over time.
Personal Standards and Self-Critical Perfectionism Dimensions
One of the earlier descriptions of perfectionism characterized it as a unidimensional
construct representing black and white thinking that resolves around complete success or
complete failure (Barrow & Moore, 1983; Burns, 1980). More specifically, Burns (1980)
described perfectionism as the setting of unrealistic goals and standards, the compulsive striving
to achieve these impossible standards, as well as the defining of self-worth as based on external
success and productivity. Hamachek (1978) was the first to describe perfectionism as a dual
concept that incorporated both ‘normal perfectionists’ and ‘neurotic perfectionists’. Normal
perfectionists were seen as setting realistic standards for themselves and deriving pleasure from
difficult situations. Neurotic perfectionists, on the other hand, were seen as placing impossibly
high demands on themselves and experiencing little satisfaction with their efforts.
Over the last three decades, the concept of perfectionism has evolved, and has been
conceptualized as a multidimensional construct that has been described in a multitude of ways
(see Flett & Hewitt, 2002). Three main conceptualizations that have been the focus of a
significant portion of the perfectionism literature include those of Frost and colleagues (Frost,
Marten, Lahart, & Rosenblate, 1990), Hewitt and Flett (1991), and Slaney and colleagues
(Slaney, Rice, Mobley, Trippi, & Ashby, 2001). Frost and colleagues (1990) viewed
perfectionism as consisting of several varying aspects, specifically concern over mistakes, doubts
about actions, personal standards, parental expectations, parental criticism, and organization.
Further, Frost and colleagues (1990) emphasized the critical distinction between setting and
striving for high personal standards, which they suggested was not inherently maladaptive, in
3
comparison to concern over mistakes, which is more in line with the maladaptive aspects of
perfectionism. Hewitt and Flett (1991) defined perfectionism as comprising both personal (selforiented perfectionism) and social aspects (socially prescribed perfectionism and other-oriented
perfectionism). Socially prescribed perfectionism has been more consistently related to negative
outcomes than either self- or other- oriented perfectionism. Lastly, Slaney and colleagues (2001)
viewed perfectionism as comprising both adaptive (consisting of setting high standards and order
for oneself) and maladaptive aspects (consisting of a discrepancy between one’s standards and
their perceived reality).
As an extension of these important conceptualizations, factor analytic studies have
consistently yield two higher-order factors that cut across the various multidimensional
conceptualizations of perfectionism (see Dunkley, Blankstein, Masheb, & Grilo, 2006; Stoeber
& Otto, 2006). These two-higher order dimensions consist of both an adaptive component and a
relatively more maladaptive component, which have been referred to as personal standards (PS)
perfectionism and self-critical (SC) perfectionism, respectively (e.g., Dunkley et al., 2003). PS
perfectionism involves setting and striving for high standards and goals for oneself (Dunkley et
al., 2003). PS perfectionism is based on a combination of measures, including the personal
standards scale of the Frost et al. (1990) Multidimensional Perfectionism Scale (FMPS), the selforiented perfectionism scale of the Hewitt and Flett (1991) Multidimensional Perfectionism
Scale (HMPS), and the high standards scale of the Slaney et al. (2001) revised Almost Perfect
Scale (APS-R). SC perfectionism, on the other hand, involves chronically critical views of
oneself, relentless and harsh self-scrutiny, and frequent concerns regarding others’ criticism and
disapproval (e.g., Dunkley et al., 2003). SC perfectionism measures include HMPS socially
prescribed perfectionism, FMPS concern over mistakes, APS-R discrepancy, as well as the self-
4
criticism scores of the Depressive Experiences Questionnaire (DEQ; Blatt, D'Afflitti, & Quinlan,
1976) and the Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978; see Dunkley, Ma,
Lee, Preacher, & Zuroff, 2014; Powers, Zuroff, & Topciu, 2004).
Perfectionism Dimensions and Psychological Difficulties
The contrast between SC and PS perfectionism can be readily understood by examining
their differential relations to psychological difficulties. Higher levels of SC perfectionism facets
have been consistently associated with depressive symptoms as well as anxious symptoms (e.g.,
Dunkley & Blankstein, 2000; Enns & Cox, 1999; Juster et al., 1996; Powers, et al., 2004;
Saboonchi, Lundh, & Ost, 1999). On the other hand, PS perfectionism dimensions often
demonstrate a negligible association with depressive and anxious symptoms (e.g., Dunkley,
Blankstein, Halsall, Williams, & Winkworth, 2000; Dunkley et al., 2003; Enns & Cox, 1999).
Moreover, the relationship between facets of SC perfectionism and negative outcomes has also
been demonstrated spanning periods of up to several years (Dunkley, Mandel, & Ma, 2014;
Dunkley, Sanislow, Grilo, & McGlashan, 2009; Rice, Leever, Christopher, & Porter, 2006;
Sherry, Richards, Sherry, & Stewart, 2014). Evidently, the above research highlights that SC
perfectionism, in contrast to PS perfectionism, serves as a primarily maladaptive dimension of
perfectionism in the development of psychosocial maladjustment (see Dunkley, Zuroff, &
Blankstein, 2006). Equally concerning is the fact that maladaptive perfectionism has been found
to negatively impede therapeutic interventions and has been shown to negatively impact the
therapeutic process (see Blatt & Zuroff, 2005; Kannan & Levitt, 2013). To elaborate, Zuroff and
Blatt (2002) evaluated whether perfectionism (measured using the DAS) impacted the
effectiveness of treatment for depressed patients undergoing short-term treatment with cognitivebehavior therapy (CBT), interpersonal therapy (IPT), medication plus clinical management, or
5
placebo plus clinical management. Results showed that individuals with greater levels of
perfectionism at the end of treatment were significantly more prone to depression when
encountering high levels of stress following treatment than those with low levels of
perfectionism.
Given that SC perfectionism is closely linked with negative outcomes over time, and that
it also serves as an obstacle in psychotherapy aiming to target these problematic outcomes, it is
crucial that research aim to better identify what explains the relationship between SC
perfectionism and psychological difficulties in order to better tailor interventions. The overall
purpose of my dissertation is to examine daily emotional reactivity as an important mechanism
that helps to explain the relationship between SC perfectionism and a variety of negative
outcomes. This explanatory variable will ideally serve as a potential target for future
interventions.
Perfectionism Diathesis-Stress Model
A theoretical framework that may help to identify important explanatory variables in the
relationship between SC perfectionism and negative outcomes is referred to as the perfectionism
diathesis-stress model. The perfectionism diathesis-stress model states that when individuals
with high levels of SC perfectionism experience stressful situations, they are more at risk for the
onset of distress outcomes (Chang & Rand, 2000; Flett, Hewitt, Blankstein, & Mosher, 1995).
This model has been tested in a sample of undergraduates, where findings showed that
individuals with higher levels of socially prescribed perfectionism (an aspect of SC
perfectionism) in conjunction with higher levels of stress produced higher levels of depressive
symptomatology (Flett, et al., 1995). Similar findings have been found over short periods of
time, such that high levels of socially prescribed perfectionism interacted with perceived stress to
6
predict increases in distress levels in undergraduates over a period of four to five weeks (Chang
& Rand, 2000). Moreover, measures of SC perfectionism in combination with stressful life
events have been shown to predict depression levels over a period of five months (Enns, Cox, &
Clara, 2005). This vulnerability likely stems from the fact that SC perfectionism is thought to
develop in response to disrupted parent-child relationships that include harsh and punitive
parenting and approval that is conditional upon the child meeting unrealistic expectations (see
Blatt, 1995; Flett, Hewitt, Oliver, & Macdonald, 2002). As a result, children begin to develop a
need for control over their environment in order to avoid parental rejection and criticism. Thus,
stressors represent a potential inability to maintain control, which leads these individuals to react
to stressors with a helplessness orientation. This results in an increased vulnerability to stressors
over the long term (Blatt, 1995; Flett & Hewitt, 2002).
The above research used between-persons designs to demonstrate that higher SC
perfectionism in combination with greater average levels of stress predicts negative outcomes.
Interestingly, however, theory and research has suggested that how an individual reacts to an
event, as opposed to the event itself, may be an important predictor of negative outcomes (Beck,
Rush, Shaw, & Emery, 1979; Charles, Piazza, Mogle, Sliwinski, & Almeida, 2013). To
elaborate, cognitive biases may interfere with an individual’s ability to regulate emotions in the
presence of stressful situations, which may have an impact on psychological difficulties over
time (Alford & Beck, 1997; Gunthert, Cohen, Butler, & Beck, 2005). In order to investigate
whether an individual’s emotional response to a stressor plays a role in predicting negative
outcomes, within-person designs must be employed in order to capture multiple assessments of
both appraisals and mood over time, better clarifying the typical emotional triggers for higher SC
perfectionists in their day-to-day lives. Within-person designs address the clinically relevant
7
question of whether changes in daily levels of perceived stressors contributes to changes in daily
affect within an individual over time.
Perfectionism and Emotional Reactivity
Research has begun to investigate the role of personality on the relationship between
appraisals and emotion, and findings have supported the notion that certain personality
vulnerabilities contribute to greater emotional reactivity (Dunkley, Mandel, et al., 2014; Suls &
Martin, 2005; Tong, 2010), which is defined as the strength of an individual’s relationship
between daily stressors and corresponding changes in mood (L. H. Cohen, Gunthert, Butler,
O'Neill, & Tolpin, 2005). To elaborate, higher levels of emotional reactivity occur when greater
increases in daily stressors are coupled with higher levels of daily negative mood. In other
words, two people may appraise an event as equally stressful, however one individual may have
a more exaggerated negative emotional response to that appraisal than the other.
The relationship between SC perfectionism and emotional reactivity has recently been
examined, whereby Dunkley, Mandel, et al. (2014) assessed whether higher SC perfectionists
exhibit daily emotional reactivity over the long term in a sample of community adults.
Participants completed baseline questionnaires of personality, and then six months and three
years later provided daily dairy reports of daily stressful events (event stress and negative social
interactions) and corresponding mood for 14 consecutive days. This way, the authors were able
to examine whether higher SC perfectionism in combination with increases in perceived stressors
predicted increases in both global and specific affect states (i.e., negative affect and sadness,
respectively) at two separate time points over a period of three years. Multilevel modeling of
cross-level interactions showed that individuals with higher levels of SC perfectionism reported
higher levels of daily sadness and negative affect when appraising their most bothersome event
8
of the day as more stressful six months and three years later. Results also showed that SC
perfectionists experienced increases in sadness- but not negative affect- when experiencing
increases in negative social interactions at month six and year three. These findings demonstrate
that individuals with greater levels of SC perfectionism are emotionally reactive to both higher
stress levels and increases in negative social interactions over time.
Interestingly, these results also point to the importance of measuring both broad (i.e.,
negative affect) and specific (i.e., sadness) emotional states, as individuals with personality
vulnerabilities may be more likely to respond to stressors with certain emotions as opposed to
others (Watson, Clark, & Stasik, 2011). To elaborate, specific emotions such as sadness are
thought to represent distinct aspects of negative mood that are not readily captured in broader
constructs such as negative affect (Watson et al., 2011). Sadness encompasses internalizing
emotions such as feeling lonely, blue, or downhearted, whereas negative affect taps into both
internalizing and externalizing emotions such as anger and frustration (Watson et al., 2011).
Further, emotions such as anger and frustration may comprise certain adaptive components as
they encourage individuals to more readily engage with the presenting stressor, whereas sadness
may lead an individual to respond with more withdrawal and avoidance (see Carver & HarmonJones, 2009, for a review; Lindebaum & Jordan, 2014). The fact that higher SC perfectionists
have been found to be more consistently reactive to stressors with sadness, as opposed to
negative affect, is consistent with the finding that individuals with higher SC perfectionism are
known to employ avoidance as a coping strategy when encountering stressors (Dunkley, Ma, et
al., 2014).
9
Perfectionism, Emotional Reactivity, and Negative Outcomes
Research thus far has highlighted links between SC perfectionism and negative outcomes
(see Egan, Wade, & Shafran, 2011, for a review), as well as SC perfectionism and emotional
reactivity (Dunkley, Mandel, et al., 2014). However, researchers have yet to examine whether
emotional reactivity helps to explain the relationship between SC perfectionism and a wide range
of negative outcomes over time. Emotional reactivity as a predictor variable represents the
strength of the relationship between daily stress appraisals and mood within an individual over
time. More specifically, daily diaries are used to gather multiple measurements of daily stressors
and mood over a period of time, and then multilevel modeling is employed to create an
emotional reactivity variable, which represents the degree to which an individual’s mood
fluctuates in response to a given stress appraisal. To elaborate, this emotional reactivity variable
is developed and represents each individual’s slope between daily stress and mood, which is then
used as an independent predictor, mediator or moderator variable in future analyses (L. H. Cohen
et al., 2005; Cole et al., 2014).
Emotional reactivity may be an especially relevant mediator/moderator of the relationship
between SC perfectionism and distress, as it has been linked to negative outcomes in previous
research (Cohen, et al., 2005). More specifically, Gunthert et al. (2005) examined the impact of
daily emotional reactivity (i.e., the relationship between daily negative mood and patients'
undesirability appraisal of their day’s worst event) on the effectiveness of treatment in depressed
outpatients undergoing cognitive therapy. The authors found that patients who exhibited
heightened emotional reactivity at the start of treatment benefited less from treatment than those
who were low on emotional reactivity. Further, Wichers et al. (2009) assessed the prospective
impact of daily emotional reactivity to stress (referred to as stress sensitivity) on depressive
10
symptoms over a period of approximately 1 year, and found that higher stress sensitivity was a
significant predictor of major depression over time. Moreover, emotional reactivity to stress has
been shown to predict distress, chronic physical health conditions, and a greater likelihood of
having a mood disorder over a period of 10 years (Charles et al., 2013; Piazza, Charles,
Sliwinski, Mogle, & Almeida, 2013).
Research on the prospective impact of emotional reactivity has not simply focused on the
coupling between affect and daily stress appraisals, but has expanded to include important
relationships between affect and other forms of appraisal as well. O'Neill, Cohen, Tolpin, and
Gunthert (2004) tested the role of daily emotional reactivity to daily interpersonal stressors in a
sample of undergraduates over of a period of two months. Findings showed that students who
were emotionally reactive to daily interpersonal stressors at baseline had greater increases in
depressive symptoms two months later. Emotional reactivity to interpersonal stressors, also
referred to as interpersonal sensitivity, has also been theorized to partially explain the
relationship between SC perfectionism and stress generation (Hewitt & Flett, 2002). The stress
generation perspective suggests that certain individuals actively construe and respond to their
environments in ways that contribute to the occurrence of stress in their lives, leading to an
increase in dependent stressful life events (Hammen, 1991; Hewitt & Flett, 2002). Moreover,
stress generation processes have largely been found for dependent interpersonal events in
particular (Hammen, 1991; Shih, Abela, & Starrs, 2009). Interpersonal sensitivity may help to
explain the relationship between SC perfectionism and interpersonal stress generation outcomes
because overreacting to interpersonal stressors may transform nonthreatening interpersonal
situations into stressful encounters over time (see Hewitt & Flett, 2002; Zuroff, Mongrain, &
Santor, 2004).
11
Evidently, various forms of emotional reactivity have been shown to negatively impact
individuals in myriad ways over significant periods of time. Thus, emotional reactivity may
serve as an important explanatory variable in the relationship between SC perfectionism and
psychosocial maladjustment over time. However, research has not yet examined whether
emotional reactivity contributes to the development of negative outcomes for higher SC
perfectionists several years later.
SC Perfectionism and Biomarkers of Psychological Stress
Given that the above research suggests that emotional reactivity to stressors may serve as
a possible link between SC perfectionism and negative outcomes, it is feasible that physiological
measures of stress may be relevant in this relationship as well. Salivary cortisol, a stress hormone
that represents a reliable measure of the hypothalamus-pituitary-adrenal (HPA) axis, is known to
play an important role in physical and mental health outcomes (Hellhammer, Wüst, & Kudielka,
2009; Rodrigues, LeDoux, & Sapolsky, 2009).
Research has begun to examine the relationship between SC perfectionism and salivary
cortisol. Wirtz et al. (2007) had a sample of 50 men complete measures of concern over mistakes
and doubts (a facet of SC perfectionism) and undergo the Trier Social Stress Test (TSST;
Kirschbaum, Pirke, & Hellhammer, 1993), where participants partake in a mock job interview
and perform a mental arithmetic test. Participants provided salivary cortisol samples at multiple
time points following the TSST, as well as multiple times throughout the day for a week
following their lab visit. Results demonstrated that individuals with high levels of perfectionism
had a significantly higher cortisol response to the psychosocial stressor than those with low
perfectionism scores. McGirr and Turecki (2009) completed a similar study with 16 men and
women, where SC perfectionism was assessed by the Depressive Experiences Questionnaire
12
(DEQ). Results demonstrated that SC perfectionism was not related to cortisol reactivity.
However, it is difficult to draw conclusions from these findings because the TSST did not
stimulate a cortisol response in these participants. On the other hand, findings did show that
higher SC perfectionism was related to increases in alpha-amylase, which is considered to be
another important biomarker marker for stress-related processes (Nater & Rohleder, 2009). More
recently, Richardson, Rice, and Devine (2014) showed that maladaptive perfectionism was
associated with a lower cortisol response to the TSST. Lastly, Kempke, Luyten, Mayes, Van
Houdenhove, and Claes (2015) examined the relationship between SC perfectionism, cortisol in
response to the TSST, and chronic fatigue syndrome (CFS) in 43 women. They found that SC
perfectionism was associated with a blunted cortisol reaction to the TSST, and that cortisol
reactivity was inversely related to symptom severity. The above research suggests that there
exists a link between SC perfectionism and dysregulated physiological stress processes.
However, research has yet to examine the relationship between SC perfectionism and cortisol
activity in daily life. Assessing the role of daily cortisol activity may help to further elucidate the
relationship between SC perfectionism, salivary cortisol and negative outcomes.
Both diurnal cortisol secretion and the cortisol awakening response (CAR) provide
consistent, noninvasive measurements of daily cortisol activity that do not require the
administration of stressor tasks (Carnegie et al., 2014; Chida & Steptoe, 2009; Kudielka & Wüst,
2010; Pruessner et al., 1997). Diurnal cortisol secretion represents the overall amount of cortisol
release throughout the day, and is measured as the area under the curve with respect to ground
(AUCg; Pruessner, Kirschbaum, Meinlschmid, & Hellhammer, 2003). Both increased and
decreased diurnal cortisol levels have been associated with distress outcomes, namely depression
levels (Gold, Licinio, Wong, & Chrousos, 1995; Pfohl, Sherman, Schlechte, & Winokur, 1985;
13
Vreeburg et al., 2013; Vreeburg et al., 2009). The CAR, on the other hand, represents an increase
in cortisol that occurs upon awakening, which has been linked to both adaptive (Clow,
Hucklebridge, Stalder, Evans, & Thorn, 2010; Hoyt, Zeiders, Enrilich, & Adam, 2016) as well as
maladaptive outcomes (Adam et al., 2010; Vrshek-Schallhorn, 2013). Given that there appears to
be a relationship between SC perfectionism and cortisol activity, and that cortisol activity has
been related to distress outcomes in some but not all research, it is possible that personality
differences may play a role in explaining these mixed results. More specifically, as previous
research has suggested that SC perfectionism interacts with higher levels of stress to predict
depression (Chang, 2000; Enns & Cox, 2005), it is possible that higher levels of diurnal cortisol
or CAR may exacberate or maintain the impact of SC perfectionism on distress symptoms over
time.
Gaps in Previous Research
The current literature in the realm of perfectionism, emotional reactivity, and
psychosocial maladjustment has documented links between these processes; however, the
literature has been limited in a number of ways. Firstly, research has yet to explicitly examine
whether emotional reactivity explains why, or under which conditions, SC perfectionism relates
to negative outcomes. As described above, higher levels of emotional reactivity may play a role
in the relationship between SC perfectionism and psychological difficulties because how on
reacts an event may be a better predictor of negative outcomes than the event itself (Beck et al.,
1979). One previous study has examined whether emotional reactivity explains the relationship
between SC perfectionism and distress outcomes; however, this research employed one-time
questionnaires to examine emotional reactivity (Aldea & Rice, 2006). Daily diaries, as opposed
to one-time questionnaires, provide more detailed information regarding multiple instances of
14
stress and mood fluctuations, which help to better capture an individual’s daily emotional
triggers. In addition, though daily dairies have been previously used to examine the impact of SC
perfectionism on daily fluctuations between stress appraisals and mood (Dunkley, Mandel, et al.,
2014), research has yet to create individual emotional reactivity slopes for SC perfectionists that
represent the strength of an individual’s relationship between stress and mood, which can then be
used as independent variables to examine increasingly complex mediator and moderator
hypotheses.
Furthermore, previous studies that have assessed SC perfectionism, emotional reactivity,
and negative outcomes have only spanned periods of up two months (Aldea & Rice, 2006;
Luyten et al., 2011). Research that spans a longer period of time helps to clarify the long-term
impact of emotional reactivity in individuals with higher levels of SC perfectionism, and
therefore helps to highlight whether emotional reactivity would serve as an important
intervention target for these individuals. Moreover, though personality is considered to be quite
stable (McCrae & Costa, 2008), there is currently little understanding regarding the stability of
emotional reactivity. Emotional reactivity is inherently less stable than core personality traits;
however, it captures important situation-specific vulnerabilities that highlight the unique pattern
of individual’s emotional response to daily stressors (Singer, 2013; Sliwinski, Almeida, Smyth,
& Stawski, 2009). In addition, little research has examined measures of emotional reactivity in
addition to physiological measures of stress in order to better clarify the importance of these two
distinct processes in the relationship between SC perfectionism and negative outcomes. Lastly,
research has yet to examine whether emotional reactivity has an impact on the relationship
between SC perfectionism and negative outcomes across community and clinical samples.
15
The Present Thesis
In the current thesis, I aim to address these gaps in several novel ways with the goal of
developing a better understanding of the mechanisms that help to explain the relationship
between SC perfectionism and psychological difficulties over time. The three articles in this
thesis utilize longitudinal data spanning periods of up to four years in order to better examine the
role of emotional reactivity in the relationship between SC perfectionism and subclinical
depressive and anxious symptoms, stress generation, and clinical depression maintenance over
time. Furthermore, the articles utilize daily dairies to develop emotional reactivity variables that
represent each individual’s relationship between daily stress appraisals and corresponding mood.
Moreover, both articles 1 and 2 assess emotional reactivity at two separate time points 2.5 years
apart, allowing for the examination of the stability of emotional reactivity over time.
Article 1 seeks to better understand the relationship between SC perfectionism and
increases in depressive and anxious symptoms over a period of four years in a sample of
community adults. This research examines the role of stress reactivity (i.e. increases in negative
mood in response to increases in stress appraisals) at both Month 6 and Year 3 as potential
explanatory variables in this relationship. Article 1 also examines whether responding to stress
with sadness, as opposed to broader negative affect, differentially predicts negative outcomes in
individuals with higher SC perfectionism. Lastly, article 1 also aims to investigate Beck and
colleagues’ (1979) hypothesis that suggests that stress reactivity, as opposed to average stress
levels, better predicts psychological distress outcomes over time.
Article 2 aims to expand upon previous theory and research suggesting links between SC
perfectionism, interpersonal sensitivity, and stress generation (see Hewitt & Flett, 2002; Zuroff,
Mongrain, & Santor, 2004). More specifically, article 2 utilizes daily interpersonal sensitivity
16
slopes (i.e. slopes that represent an individual’s daily negative mood in response to daily
negative social interactions) six months and three years after baseline as mediators of the
relationship between SC perfectionism and interpersonal stress generation over a period of four
years. Stress generation was assessed using a contextual-threat interview (Hammen, 1991),
which allows for objective ratings of severity, dependence, and interpersonal features of stressful
life events. Using this interview, article 2 examines whether interpersonal sensitivity
differentially mediates the relationship between SC perfectionism and interpersonal versus
noninterpersonal stress generation as well as independent stress. Article 2 also examines whether
responding to negative social interactions with more discrete versus broad emotions (i.e., sadness
versus negative affect) differentially predicts stress generation for SC perfectionistic individuals.
Finally, article 2 also seeks to further test Beck and colleagues’ suggestion that greater levels of
emotional reactivity (in this case interpersonal sensitivity) better predicts problematic outcomes
in comparison to average levels of negative social interactions.
Article 3 addresses a slightly different question than do articles 1 and 2, as it examines
the moderating role of stress reactivity in the relationship between SC perfectionism and
depression over a period of one year in a sample of clinically depressed outpatients. Article 3
incorporates multiple measures of cortisol activity (i.e., diurnal cortisol levels and changes in
cortisol in response to awakening) in order to examine additional stress processes and to further
explore the relevance of important physiological processes in personality research. Article 3
specifically addresses the critical question of whether stress reactivity and/or cortisol activity
serve as obstacles that may illuminate the conditions under which SC perfectionistic individuals
are especially resistant to psychotherapy treatment for depression (Zuroff & Blatt, 2002). Thus,
17
article 3 helps to explore under which conditions higher SC perfectionists are most at risk for the
maintenance of their depressive symptoms over time.
Taken together, the present thesis addresses critical issues in the domain of perfectionism
research by examining important mediators and moderators of the relationship between SC
perfectionism and negative outcomes. The use of emotional reactivity measures provides a novel
contribution to current literature by incorporating variables that have yet to be explicitly linked to
SC perfectionism, but that have demonstrated their destructive nature in previous research. The
current thesis helps to elucidate the importance of various forms of emotional reactivity in the
relationship between SC perfectionism and psychological difficulties in order to identify
potential targets for future interventions. Finally, this thesis also addresses important questions
concerning the potentially differing role of emotional reactivity in both community and clinical
samples by examining the impact of emotional reactivity for SC perfectionists in community
samples in article 1 and 2 and in a depressed sample in article 3.
18
Article 1
Self-Critical Perfectionism and Depressive and Anxious Symptoms Over Four Years:
The Mediating Role of Daily Stress Reactivity
Tobey Mandel, David M. Dunkley, and Molly Moroz
Lady Davis Institute–Jewish General Hospital and McGill University
Mandel, T., Dunkley, D. M., & Moroz, M. (2015). Self-critical perfectionism and depressive and
anxious symptoms over four years: The mediating role of daily stress reactivity. Journal of
Counseling Psychology, 62, 703-717.
19
Abstract
This study of 150 community adults examined heightened emotional reactivity to daily
stress as a mediator in the relationships between self-critical (SC) perfectionism and depressive
and anxious symptoms over a period of four years. Participants completed questionnaires
assessing: perfectionism dimensions, general depressive symptoms (i.e., shared with anxiety),
specific depressive symptoms (i.e., anhedonia), general anxious symptoms (i.e., shared with
depression), and specific anxious symptoms (i.e., somatic anxious arousal) at Time 1; daily stress
and affect (e.g., sadness, negative affect) for 14 consecutive days at Month 6 and Year 3; and
depressive and anxious symptoms at Year 4. Path analyses indicated that SC perfectionism
predicted daily stress-sadness reactivity (i.e., greater increases in sadness in response to increases
in stress) across Month 6 and Year 3, which, in turn, explained why individuals with higher SC
perfectionism had more general depressive symptoms, anhedonic depressive symptoms, and
general anxious symptoms, respectively, four years later. In contrast, daily reactivity to stress
with negative affect did not mediate the prospective relation between SC perfectionism and
anhedonic depressive symptoms. Findings also demonstrated that higher mean levels of daily
stress did not mediate the relationship between SC perfectionism and depressive and anxious
symptoms four years later. These findings highlight the importance of targeting enduring
heightened stress reactivity in order to reduce SC perfectionists' vulnerability to depressive and
anxious symptoms over the long-term.
Keywords: self-criticism, perfectionism, stress reactivity, depression, anxiety
20
Self-Critical Perfectionism and Depressive and Anxious Symptoms Over Four
Years: The Mediating Role of Daily Stress Reactivity
The American Psychological Association’s (e.g., 2014) annual Stress in America survey
has established that the presence of high stress in our current culture propagates unhealthy
outcomes for individuals, such as mood and anxiety symptoms. Perfectionism is an important
personality characteristic that has been associated with adverse reactions to stress (e.g., Dunkley,
Mandel, & Ma, 2014), and is a transdiagnostic vulnerability factor for depression, anxiety, and
various other disorders (see Dunkley, Blankstein, Masheb, & Grilo, 2006; Egan, Wade, &
Shafran, 2011; Flett & Hewitt, 2002). There have been a variety of different conceptualizations
and measures of perfectionism dimensions (Blatt, D'Afflitti, & Quinlan, 1976; Frost, Marten,
Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991; Slaney, Rice, Mobley, Trippi, & Ashby,
2001; Weissman & Beck, 1978). However, an important advancement in our current
understanding of perfectionism indicates that the construct is composed of two higher-order
dimensions, namely personal standards (PS) and self-critical (SC) perfectionism (Dunkley,
Blankstein, et al., 2006; Stoeber & Otto, 2006). PS perfectionism is the orienting and striving
towards high standards and important goals set for oneself. Alternatively, SC perfectionism
involves relentless, severe self-scrutiny, frequent concerns about mistakes, and intensely critical
views of oneself that are associated with preoccupations regarding others’ disapproval and
criticism (Dunkley, Zuroff, & Blankstein, 2003).
Prior research has established that, in contrast to PS, SC perfectionism is more
consistently associated with negative outcomes, such as depressive and anxious symptoms (see
Dunkley, Blankstein, et al., 2006; Stoeber & Otto, 2006). Further, this relationship has been
demonstrated in longitudinal studies spanning periods of up to several years (Dunkley, Sanislow,
21
Grilo, & McGlashan, 2006, 2009; Rice, Leever, Christopher, & Porter, 2006; Sherry, Richards,
Sherry, & Stewart, 2014). In addition, when therapy has attempted to address these issues, SC
perfectionism has been found to have a negative impact on the therapeutic process as well as
treatment outcomes (see Blatt & Zuroff, 2005; Kannan & Levitt, 2013). In instances where
individuals (e.g., those with higher SC perfectionism) are particularly impervious to change,
clinicians must develop longitudinal explanatory conceptualizations to help clarify why clients
experience the same difficulties in various situations over time (Kuyken, Padesky, & Dudley,
2009). This way, therapists and clients can work together to tailor interventions which better
target the underlying mechanisms that contribute to their distress. The present study examined
whether enduring stress reactivity explains the relationship between SC perfectionism and both
depressive and anxious symptoms four years later.
Perfectionism, Daily Stress Reactivity, and Depressive and Anxious Symptoms
Longitudinal explanatory conceptualizations aim to explain the relationship between a
client’s developmental history, core beliefs, and underlying assumptions which then lead clients’
to experience heightened emotional reactivity in response to various life situations (see Kuyken
et al., 2009). This heightened emotional reactivity may then help to explain why SC
perfectionists suffer from depressive and anxious symptoms over the long-term. An important
theoretical model that may help us to understand heightened emotional reactivity in SC
perfectionists is the diathesis-stress model. The perfectionism diathesis-stress model states that
when highly perfectionistic individuals encounter high levels of stress, they are more at risk for
the development of depressive/distress symptoms (Chang & Rand, 2000; Flett, Hewitt,
Blankstein, & Mosher, 1995). This likely occurs because SC perfectionism is thought to develop
in response to conditional parental approval that is based upon meeting unreasonably high
22
parental expectations in combination with harsh and punitive parenting (see Blatt, 1995; Flett,
Hewitt, Oliver, & Macdonald, 2002; Enns, Cox, & Clara, 2002). Theory and research suggests
that children whose parents exhibit this type of parenting style desire the need for control in
order to avoid parental rejection. Perceived stressors represent a potential failure to retain
control, leading these individuals to respond with a helplessness orientation in the face of
negative events. These children then exhibit an increased vulnerability to stressors later in life
(Blatt, 1995; Flett et al., 2002; Enns et al., 2002).
The perfectionism diathesis-stress model was tested in undergraduates, and results
demonstrated that those with high levels of socially prescribed perfectionism (a facet of SC
perfectionism) combined with high levels of negative life stress had higher concurrent levels of
depressive symptoms (Flett et al. 1995). In addition, high levels of socially prescribed
perfectionism in combination with high levels of self-reported stress predicted increases in
distress symptoms in undergraduate students over a period of four to five weeks (Chang and
Rand, 2000). Finally, SC perfectionism measures (i.e., socially prescribed perfectionism, concern
over mistakes) have been found to interact with stressful life events to predict higher scores of
depression five months later (Enns, Cox, and Clara, 2005).
Though this prior research has helped to identify a relationship between SC
perfectionism, stress, and negative outcomes, it also contains important limitations. These
previous studies employed a between-persons design, which focuses on whether SC
perfectionism in conjuction with individual differences in levels of stress predict individual
differences in negative outcomes. Between-persons designs address fundamentally different
questions than within-person designs, which address pertinent questions of whether changes in
daily stress covary with changes in daily affect within an individual (see Dunkley et al. 2003).
23
Within-person designs allow for multiple assessments of stress and affect, which are necessary in
order to better identify an individual’s typical emotional triggers. This process mimics that which
occurs in therapy, whereby the therapist and client gather various examples of the clients’
thoughts, mood, and behaviors in response to present day events. Therapists then create crosssectional explanatory conceptualizations by identifying patterns across situations that trigger
negative emotional reactions in the client.
In previous analyses of the same sample as the present study, Dunkley, Mandel, and Ma
(2014) used repeated sequences of daily diaries to assess the prospective moderating role of SC
perfectionism on the within-person associations between daily event stress and both sadness and
negative affect at two separate time points six months and three years later. Multilevel modeling
of cross-level interactions showed that within-person associations between daily stress and both
sadness and negative affect varied as a function of between-persons differences in SC
perfectionism at Month 6 and Year 3. That is, individuals higher on SC perfectionism, relative to
those lower, reported greater increases in sadness and negative affect on days when they
experienced higher levels of daily stress than usual, both six months and three years later. These
findings demonstrate how repeated daily diary methodologies can help therapists to better predict
a client’s future reactions to daily stress. Although the Dunkley, Mandel, et al. (2014) findings
provide initial support for therapists and SC perfectionistic clients working together to create
interventions to overcome intensified affective reactions to daily stress, further work is needed to
elaborate on these findings in four important ways.
First, Dunkley, Mandel, et al. (2014) did not examine whether daily stress reactivity
serves as an important mediating mechanism that explains why individuals with higher SC
perfectionism have heightened vulnerability to distress symptoms (e.g., depressive, anxious) over
24
time. Heightened stress reactivity of individuals with higher SC perfectionism appears to be
relevant given that theorists have posited that how one reacts to an event, as opposed to the
actual event itself, predicts psychological outcomes (Beck, Rush, Shaw, & Emery, 1979;
Charles, Piazza, Mogle, Sliwinski, & Almeida, 2013). Only one study has explored the
relationship between perfectionism and psychological distress via affective reactivity. In a crosssectional study, Aldea & Rice (2006) found that emotional dysregulation fully explained the link
between SC perfectionism and distress, emphasizing the importance of emotional regulation in
the relationship between SC perfectionism and negative outcomes. However, emotional
dysregulation was measured using a one-time questionnaire. Unlike daily dairies, one-time
questionnaires do not assess multiple situations in which SC perfectionists experience shifts in
mood, and therefore do not capture dynamics regarding an individual’s emotional triggers. In
addition, this cross-sectional study did not address whether stress reactivity explains the
prospective association between SC perfectionism and distress symptoms over time.
Stress reactivity as a predictor variable is not simply the measurement of either stress or
affect variables alone, it is the dynamic coupling between stress and mood within an individual
over time. This novel method of analysis uses daily diaries to collect a series of data points of
stress and affect over time, and then multilevel modeling is used to yield a strength-ofassociation variable, which reflects the degree to which stress triggers mood in a given
individual. That is, an individual slope is generated for each participant that can then be used as
an independent or mediator variable in order to test substantive hypotheses (L. H. Cohen,
Gunthert, Butler, O'Neill, & Tolpin, 2005; Cole et al., 2014; Wichers et al., 2009). Using this
method, L. H. Cohen et al. (2005) found that daily affective reactivity to stress prospectively
predicted depressive symptoms. Daily stress reactivity has also been found to be a prospective
25
predictor of affective symptoms over a period of approximately one year (Wichers et al., 2009).
Charles et al. (2013) found that affective reactivity to stress at baseline predicted affective
distress and a higher chance of having a mood disorder 10 years later. The previous findings
highlight the impact of emotional reactivity on overall well-being, which, importantly, suggests
that stress reactivity may be a potential mediator in the relationship between SC perfectionism
and negative outcomes.
Second, Dunkley, Mandel, et al. (2014) demonstrated that SC perfectionists were
emotionally reactive to stress at both Month 6 and Year 3, but these analyses were done
separately at each time point and therefore they did not assess the stability of these within-person
processes. Given that personality is considered to be a relatively stable construct (McCrae &
Costa, 2008), it is important to assess the stability of stress reactivity as well. Emotional
regulation patterns are inherently less stable than core personality traits. However, emotional
regulation tendencies highlight an important aspect of an individual’s vulnerability to mood
disorders because they explain more situation-specific vulnerabilities by representing an
enduring pattern of emotional fluctuations in response to specific stress appraisals (Singer, 2013;
Sliwinski, Almeida, Smyth, & Stawski, 2009).
Third, although Dunkley, Mandel, et al. (2014) showed that individuals with higher SC
perfectionism exhibit heightened daily stress reactivity through greater increases in both sadness
and negative affect, this study did not compare the mediating roles of reactivity to daily stress
with sadness (referred to as stress-sadness reactivity) and reactivity to stress with negative affect
(referred to as stress-NA reactivity) in explaining the prospective association between SC
perfectionism and distress outcomes over time. Though more general dimensions of affect, such
as negative affect, have been shown to relate to both depressive and anxious outcomes, sadness
26
has been conceptualized as a distinct aspect of negative mood that represents specific content not
fully captured in broader dimensions like negative affect (Watson, Clark, & Stasik, 2011).
Specifically, sadness captures low activation emotions such as feeling downhearted, lonely, and
blue, which does not include externalizing components often found in negative affect (i.e. anger,
frustration; Watson et al., 2011). By extension, emotions such as anger and frustration may elicit
protective ‘approach’ behaviors, such as coping with the presenting stressor, whereas sadness in
response to stress may elicit more withdrawal behaviors, potentially contributing to unresolved
stress and increases in anxiety over time (see Carver & Harmon-Jones, 2009 for a review;
Lindebaum & Jordan, 2014). Moreover, individuals have been shown to experience anxiety in
response to the feeling of sadness, a phenomenon referred to as “fear of sadness”, because
sadness elicits a feeling of loss of control of one’s emotions (Liverant, Brown, Barlow, &
Roemer, 2008; Taylor & Rachman, 1991). In light of these differences between sadness and
negative affect, research is needed to evaluate whether stress-sadness reactivity, as compared to
stress-NA reactivity, better captures the vulnerability of individuals with higher SC
perfectionism to distress outcomes over time.
Finally, in previous analyses of the same sample as the current study, Dunkley, Ma, Lee,
Preacher, and Zuroff (2014) showed that average daily event stress appraisals mediated the
relationship between SC perfectionism and the maintenance of daily negative and lower positive
affect six months later. Stress appraisals and stress-affect reactivity are conceptually different in
that stress appraisals reflect individual differences in levels of event stress, whereas stress-affect
reactivity variables refers to individual differences in the degree of coupling between stress
appraisal and affect, independent of the appraisal (Tong, 2010). A shortcoming of Dunkley, Ma,
et al.’s (2014) mediation analyses was that average daily stress was not tested as a possible
27
mediator of the prospective association between SC perfectionism and increases in distress
symptoms over time. Research is needed to directly examine whether it is stronger stress-affect
relations or higher daily stress that better explains why individuals with higher SC perfectionism
have heightened vulnerability to distress symptoms over time, while controlling for initial
distress symptoms.
The Present Study Aims and Hypotheses
The present study was the first to investigate the importance of daily stress reactivity as
an explanatory mechanism in the relationship between SC perfectionism and depressive and
anxious symptoms over a period of several years. In order to explore this, we conducted further
analyses of the same sample of community adults used in previous studies (Dunkley, Ma, et al.,
2014; Dunkley, Mandel, et al., 2014) who completed repeated sequences of 14 days of daily
diaries assessing daily levels of stress and affect six months and three years later. Whereas
Dunkley, Mandel, et al. (2014) used multilevel modeling of cross-level interactions to predict
changes in affect from fluctuations in daily stress, in the present study we created stress
reactivity variables that represent the strength-of-relation between a given individual’s daily
stress appraisal and affect at Month 6 and Year 3. Specifically, we created Month 6 and Year 3
stress-sadness reactivity variables that captured the degree to which stress and sadness were
coupled in each participant, which were then tested as sequential mediators in the relationship
between SC perfectionism and distress symptoms over four years.
As perfectionism is considered to be a transdiagnostic vulnerability factor to depression
and anxiety (see Egan et al., 2011), we examined whether daily stress-sadness reactivity
explained the adverse impact of SC perfectionism in predicting depressive and anxious
symptoms over the longer-term. There is consensus that SC perfectionism serves as a
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vulnerability factor for depression (Bardone-Cone et al., 2007), but the evidence for anxiety has
been mixed (Egan et al., 2011; Sherry et al., 2014). Importantly, the tripartite model (Clark &
Watson, 1991; Watson, 2009) suggests that depressive and anxious symptoms have both shared
as well as unique components. In order to better understand the mediating role of stress-sadness
reactivity in the relationship between SC perfectionism and depressive and anxious symptoms,
we assessed both general depressive and anxious symptoms (i.e. those with shared overlap) and
specific components of depression (i.e. anhedonia) and anxiety (i.e. anxious arousal) as outcomes
(Clark & Watson, 1991). In supplementary analyses, we also tested stress-NA reactivity as a
potential alternative mediator explaining the prospective associations between SC perfectionism
and depressive and anxious symptoms over four years. Finally, in supplementary analyses, we
expanded on Dunkley, Ma, et al. (2014) by evaluating aggregated levels of daily stress appraisals
(i.e., event stress) as a possible alternative mediator in the relation between SC perfectionism and
depressive and anxious symptomatology over a substantially longer period of time (i.e., 4 years)
than the shorter timeframe (six months) of the previous analyses.
Hypotheses
Based on theory and findings described above, we hypothesized that SC perfectionism
would predict both general and specific depressive symptoms over four years, controlling for
baseline symptoms. Given the mixed evidence for the link between SC perfectionism and
anxiety, we hypothesized that SC perfectionism would relate to general anxious distress
symptoms that are often found to be comorbid with depressive symptoms, but would not relate to
specific somatic arousal symptoms of anxiety that are more commonally associated with panic
disorder (Watson, 2009). Figure 1 depicts the mediation model of the hypothesized relations
among Time 1 SC perfectionism, Month 6 and Year 3 daily stress-sadness reactivity, and Year 4
29
depressive/anxious symptoms. We expected that Time 1 SC perfectionism would uniquely
predict Month 6 and Year 3 stress-sadness reactivity, Month 6 stress-sadness reactivity would
predict Year 3 stress-sadness reactivity, and Year 3 stress-sadness reactivity would predict Year
4 depressive/anxious symptoms. Given that stress reactivity is a dynamic construct that might
change reliably over time (see Sliwinski et al., 2009), we hypothesized that stress-sadness
reactivity would remain moderately stable between Month 6 and Year 3. Most importantly, we
hypothesized that enduring stress-sadness reactivity would mediate the relationship between
Time 1 SC perfectionism and general and specific depressive symptoms as well as general
anxious symptoms over four years. In addition, we hypothesized that daily stress-NA reactivity
would mediate the relation between SC perfectionism and general depressive and anxious
symptoms, but not specific symptoms, over four years. Finally, we hypothesized that aggregated
daily event stress would exhibit weaker explanatory value than daily stress reactivity in
explaining the relationship between Time 1 SC perfectionism and depressive/anxious symptoms
over four years. By addressing these questions, the present study sought to clarify whether daily
stress reactivity may serve as a suitable target for clinical intervention.
Method
Participants
The study was comprised of a sample of 150 English- and French-speaking employed,
community adults, which represented a subset of a larger sample of 223 participants. Participants
were recruited through newspaper advertisements and posted bulletins. The study involved
completion of questionnaires at Time 1, 14 daily diaries at Month 6 and Year 3, and
questionnaires at Year 4. Each participant was compensated $25 for completing the Time 1
questionnaires, $75 for each of the Month 6 diaries and Year 3 diaries, and finally $50 for the
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Year 4 questionnaires. Compensation for participants who completed fewer than 14 diaries at
Month 6 and Year 3 was adjusted in proportion to the number of diaries completed.
Participants included in the present study completed the relevant personality and
symptoms measures at Time 1, a minimum of 7 daily diaries at both Month 6 and Year 3, and the
depressive and anxious symptoms measure at Year 4. Two participants who submitted all 14
diaries at the end of their Month 6 diary record period were omitted. The final sample of 150 (45
men, 105 women) completed their first set of diaries approximately six months (M = 5.94, SD =
.38) following the Time 1 questionnaires, with 147 participants completing all 14 daily diaries,
and the remaining three participants completing between 12 and 13 diaries each. Participants
completed their second set of diaries approximately three years later (M = 36.75 months, SD =
.96), with 144 participants completing all 14 daily diaries, and the remaining six participants
completing between eight and 13 diaries each. The mean age of the sample at Time 1 was 41.02
years (SD = 12.24). Participants were largely of European descent (75%), with 7% Asian, 3%
East Indian, 3% African, 3% Middle Eastern, 2% Aboriginal, 1% Caribbean, 1% South
American, and 5% unspecified. Participants either graduated from high school (16%), college
(31%) or university (53%). Eighty-four English-speaking participants (24 male, 60 female)
completed the English version of the questionnaire packages, whereas 66 French-speaking
participants (21 male, 45 female) completed the French version of the questionnaire packages.
Procedure
At Time 1 (Fall 2006-Spring 2007), participants provided their demographic information
and completed a package of questionnaires, including measures of perfectionism and baseline
general and specific depressive and anxious symptoms, in a 1.5 to 2 hour laboratory session. Six
months (Spring 2007-Fall 2007) and again three years later (Fall 2009-Spring 2010), participants
31
were invited back to the lab to collect a package containing 14 stamped and addressed envelopes,
each containing a daily diary questionnaire booklet. Participants were explained in detail each
section of the daily diary, and were instructed to complete one daily diary at bedtime, starting
that evening, consecutively for the following 14 nights. The daily dairy booklet included
questionnaires measuring daily affect and stress appraisals. Participants were then asked to mail
the envelope with the completed daily diary to the lab the following morning. Participants were
strongly encouraged to complete their diaries every evening. If for any reason this was not
possible, participants were asked to complete them as soon as possible the following morning. At
Year 4 (Fall 2010-Spring 2011), participants were then invited back to the lab for a 60-75 minute
lab session, where they were provided another package of questionnaires, similar to Time 1,
which re-evaluated their general and specific depressive/anxious symptoms.
Measures
Questionnaire packages and diaries were available in both French and English given that
the population was bilingual. The French versions of the Time 1 perfectionism and symptom,
Month 6 and Year 3 stress appraisal and affect, and Year 4 depressive and anxious symptom
measures have been found to have similar internal consistencies and validity as their English
counterparts (see Dunkley, Blankstein, & Berg, 2012; Dunkley & Kyparissis, 2008; Dunkley,
Ma, Lee, Preacher, & Zuroff, 2014; Dunkley, Mandel, et al., 2014).
Perfectionism. SC and PS dimensions of perfectionism were derived from the following
questionnaires: the 45-item Multidimensional Perfectionism Scale (HMPS; Hewitt, Flett,
Turnbull-Donovan, & Mikail, 1991), the 35-item Multidimensional Perfectionism Scale (FMPS;
Frost et al., 1990), the 23-item Almost Perfect Scale-Revised (APS-R; Slaney et al., 2001), the
66-item Depressive Experiences Questionnaire (DEQ; Blatt et al., 1976), and the 40-item
32
Dysfunctional Attitude Scale (DAS; Weissman & Beck, 1978). The SC and PS perfectionism
measures were chosen based on previous factor analyses (e.g., Dunkley, Ma, et al., 2014;
Powers, Zuroff, & Topciu, 2004; see Stoeber & Otto, 2006 for a review). SC perfectionism was
based on DEQ self-criticism, DAS self-criticism, FMPS concern over mistakes, HMPS socially
prescribed perfectionism and APS-R Discrepancy. PS perfectionism was composed of HMPS
self-oriented perfectionism, FMPS personal standards, and APS-R high standards. As was done
in previous studies (Dunkley, Berg, & Zuroff, 2012; Dunkley, Mandel, et al., 2014; Dunkley et
al., 2003), the DEQ, DAS, FMPS, HMPS and APS-R measures were standardized and saved as
z-scores and then averaged together to create the relevant SC and PS perfectionism composite
scores. The reliability and validity of the DEQ (e.g., Zuroff, Mongrain, & Santor, 2004), DAS
(e.g., Dunkley & Kyparissis, 2008; Powers et al., 2004), APS-R (e.g., Slaney et al., 2001),
HMPS (e.g., Hewitt et al., 1991), and FMPS (e.g., Frost et al., 1990) measures have been wellestablished. Coefficient alphas for the current research for DEQ self-criticism, DAS selfcriticism, FMPS concern over mistakes, HMPS socially prescribed perfectionism, APS-R
discrepancy, FMPS personal standards, HMPS self-oriented perfectionism, and APS-R high
standards were .76 .90, .88, .88, .95, .82, .89, and .88, respectively.
Depressive and Anxious Symptoms. General and specific depressive and anxious
symptoms were measured using the Mood and Anxiety Symptom Questionnaire Short Form
(MASQ; Watson & Clark, 1991). The MASQ is a 62-item self-report questionnaire that includes
four separate scales. Two scales encompass the general aspects of depressive and anxious
symptoms (i.e. the shared measures of general distress that relate to both depressed and anxious
mood), which are referred to as the ‘general distress depressive symptoms’ (GDD; 12 items; e.g.,
“Felt pessimistic about the future”) measure and the ‘general distress anxious symptoms’ (GDA;
33
11 items; e.g., “Was unable to relax”) measure. The other two scales focus more on the specific
aspects of depression and anxiety to better differentiate between the two. These two measures are
referred to as anxious arousal (AA; 17 items; e.g., “Was trembling or shaking”) and anhedonic
depression (AD; 22 items, e.g., “Felt like it took extra effort to get started”). Individuals were
asked to rate to which degree they agreed with the statements, ranging from 1 (not at all) to 5
(extremely). Acceptable internal consistency and good convergent and discriminant validity has
been found for the MASQ scales (Reidy & Keogh, 1997; Watson et al., 1995). In the current
study, the coefficient alphas for GDD, GDA, AA, and AD at Time 1 were .92, .87, .86, and .91
and for Year 4 were .93, .86, .89, and .93, respectively.
Daily Affect. Five adjectives from the Positive and Negative Affect Schedule-Expanded
(PANAS-X; Watson & Clark, 1994) were used to assess sadness for today. In addition, the 10item negative affect scale of the PANAS (Watson, Clark, & Tellegen, 1998) was used to measure
negative affect for today. The daily ratings are considered to be reliable and valid in evaluating
these forms of affect (e.g., Dunkley, Mandel, et al., 2014). Computed using Cranford and
colleagues’ (2006) procedure, the within- and between-persons reliabilities for sadness were .57
and .65 for Month 6, and .79 and .85 for Year 3, and for negative affect were .80 and .80 for
Month 6, and .79 and .84 for Year 3, respectively.
Event Appraisals. Participants were asked to describe their most bothersome event of
today by providing details about what happened, where the event occurred, and why the event
was important. The event could be something the participant was thinking about that occurred in
their past, something that was happening today, or something that they were anticipating
happening in the future. After participants described the event itself, they were asked to rate the
event on a number of aspects: “how unpleasant was the event or issue to you?” (1 = not at all to
34
11 = exceptionally), “for how long were you bothered by the event or issue?” (1 = a very brief
amount of time to 7 = a very large amount of time), and “how stressful was the event or issue for
you?” (1 = not at all to 11 = exceptionally). Event stress was calculated by first rescaling the
length of the appraisal item score to be on an 11-point scale as opposed to a 7-point scale, and
then by taking the average of the three appraisal items (i.e. unpleasantness, length, and
stressfulness) in order to establish an event stress score that reflects both the degree and duration
of difficulty of their most bothersome event of the day. The event appraisal items have been
found to be internally consistent as well as valid (e.g., Dunkley, Ma, et al., 2014; Dunkley,
Mandel, et al., 2014; Dunkley et al., 2003). The within- and between-persons reliabilities for
event stress were computed using Cranford and colleagues’ (2006) procedure and were .86 and
.75 for Month 6, and .86 and .80 for Year 3.
Model Testing
In order to create variables to assess daily stress reactivity, we conducted multilevel
modeling using SAS PROC MIXED (Version 9.2) and maximum likelihood estimation.
Specifically, within-person daily variability in sadness and negative affect was predicted from
within-person fluctuations in event stress (with the slope modeled as randomly varying across
participants). The individual slopes were empirical Bayes estimates, and the variance associated
with these slopes was significant. The resulting regression coefficient represents a slope for each
participant, which was used as a between-persons stress reactivity variable in the path models.
Path model testing was performed using Analysis of Momentary Structure 5.0 (AMOS
Version 5.0.; Arbuckle, 2003). Based on guidelines that call for five participants per parameter
estimate (Bentler & Chou, 1987), our sample of 150 participants was sufficient in order to test
the hypothesized path models. Separate path analyses were first completed in order to test for
35
the total effects between Time 1 SC perfectionism and each Year 4 outcome variable controlling
for the respective Time 1 symptoms. Conceptually speaking, the presence of a significant total
effect implies that there is a significant direct relationship between the independent variable (SC
perfectionism) and the outcome (distress symptoms) prior to the inclusion of the relevant
mediators. Thus, if a total effect was found to be significant, then any significant indirect effect
was labeled as a mediated effect, which implies that the mediators explained an already
significant direct relationship. Alternatively, if a total effect was nonsignificant, any significant
indirect effect was labeled as an indirect effect, implying that the relationship between the
independent variable and the outcome was only explained indirectly through the mediators (see
Holmbeck, 1997; Preacher & Hayes, 2008). In essence, the outcome from the total effects
analysis indicated whether significant indirect effects from the subsequent path models were
labeled as mediated versus indirect effects.
Regardless of these initial analyses testing total effects, path model testing was performed
next to test for the mediated/indirect effects of Time 1 SC perfectionism on Year 4
depressive/anxious symptoms through Month 6 and Year 3 stress reactivity, controlling for Time
1 depressive/anxious symptoms. We considered several indices of fit, consistent with
recommendations from Hoyle and Panter (1995). Incremental fit indices (IFI) and comparative
fit indices (CFI) values above .90 (see Hoyle & Panter, 1995), and Root Mean Square Error of
Approximation (RMSEA) values below .08 suggested acceptable model fit (see Hu & Bentler,
1999). In order to establish whether the relation between SC perfectionism and each Year 4
outcome was fully or partially mediated by stress reactivity, we performed nested comparisons
between the hypothesized fully mediated model (see Figure 1) and a partially mediated model
that included a direct path between Time 1 SC perfectionism and the respective Year 4 outcome.
36
We followed Hoyle and Panter’s (1995) recommendation that competing models be compared
using chi-square difference tests and fit indices that account for model complexity. Parsimonyadjusted indices of fit compared between models were the Akaike information criterion (AIC;
Akaike, 1987) and the Bayes information criterion (BIC; Schwarz, 1978), with smaller values
preferred and the BIC tending more strongly to favor more parsimonious models (see Arbuckle,
2003). In each comparison where there was no significant difference, the more parsimonious of
the two models was accepted (see Klein, 2005).
Indirect effects were tested using the Monte Carlo Method (see MacKinnon, Lockwood,
& Williams, 2004; Preacher & Selig, 2012) for assessing mediation. We used Selig and
Preacher’s (2008) web-based utility to generate and run R code for simulating the sample
distribution of an indirect effect. Unstandardized estimates and standard errors for each path, a
95% confidence level, and 20,000 bootstrap samples created by randomly sampling and
replacing the original data are entered in order to compute confidence intervals (CI). If the CI
does not include zero, the indirect effect is considered statistically significant at the p < .05 level.
Results
Descriptive Statistics
All 150 participants completed all four time points. At Month 6, the 150 participants
completed a total of 2095 out of a possible 2100 daily dairies, measuring event stress and
sadness, where only one report was considered missing due to attrition and four reports were
missing due to item nonresponse. At Year 3, participants completed a total of 2085 reports out of
a possible 2100, where 13 were considered missing due to attrition and two were deemed
missing due to item nonresponse. Item nonresponse percentages were calculated for both the
Month 6 and Year 3 diaries and ranged between 0.2% for the sadness items and 1.5% for one of
37
the event stress appraisals. Percentages for missing variables at both time points were
approximately 0.1%. Missing data for the reactivity variables was managed using a maximum
likelihood method in SAS Version 9.2 (see Schlomer, Bauman, & Card, 2010).
The means, standard deviations, and internal consistencies for the perfectionism, stress
reactivity, aggregated stress, and MASQ variables are seen in Table 1, and are in line with those
reported in previous articles. All variables had normal skewness and kurtosis distributions except
for Anxious Arousal (AA), which had a skewed distribution. A square root transformation was
applied to anxious arousal at Time 1 and Year 4 in order to achieve a more normal distribution.
The means and internal consistencies of the Time 1 perfectionism and MASQ variables
(Dunkley, Blankstein, et al., 2012; Dunkley & Kyparissis, 2008) and the Month 6 and Year 3
daily stress and affect variables (Dunkley, Ma, et al., 2014; Dunkley, Mandel, et al., 2014) were
found to be comparable between individuals who completed the English version of the
questionnaires and individuals who completed the French version. We completed T tests on the
Year 4 MASQ variables, and found that the means were comparable between both the English
and French groups as well. In addition, given that the present sample was a subset of an original
sample of 223 participants recruited for a larger community study, T tests were performed
comparing the means of the Time 1 perfectionism and symptom measures. Results from the T
tests revealed that there were no significant differences between the current study’s subsample of
150 participants and the additional 73 participants from the original sample.
Zero-order Correlations
In Table 1, intercorrelations are presented between the following variables: Time 1 SC
perfectionism, Month 6 and Year 3 daily stress reactivity and aggregated daily stress and Time 1
and Year 4 general and specific anxious and depressive symptoms. In order to describe the
38
strength of the correlations between variables, J. Cohen’s (1992) criteria was employed for weak
(r = .10), moderate (r = .30), and strong (r = .50) effect sizes. Time 1 SC perfectionism was
moderately to strongly positively correlated with all variables. In contrast, Time 1 PS
perfectionism was negligibly or weakly related to the MASQ variables at both Time 1 and Year
4, as well as the Month 6 and Year 3 stress and reactivity variables. The Month 6 and Year 3
stress reactivity and aggregated stress measures were moderately to largely related to the Time 1
and Year 4 MASQ outcomes. In addition, Month 6 and Year 3 stress-sadness reactivity (r = .42)
and stress-NA reactivity (r = .60) were moderately to strongly correlated, whereas Month 6 and
Year 3 aggregated stress were strongly correlated (r = .68).
Path Analyses with Stress-Sadness Reactivity
There were four path models composed of Time 1 SC perfectionism and daily stresssadness reactivity at Month 6 and Year 3 predicting one of the four MASQ measures at Year 4
(i.e., general depressive symptoms, anhedonic depression, general anxious symptoms, anxious
arousal). The respective Time 1 MASQ variable was included in the model to control for
baseline symptoms (see Figure 1). The same model was tested with the addition of PS
perfectionism; however, PS did not add unique explanatory value to the path models and
therefore was not considered further, consistent with previous research (Dunkley et al., 2003).
SC perfectionism, stress-sadness reactivity, and general depressive symptoms
model. As shown in Figure 2, the total effect between Time 1 SC perfectionism and Year 4 GDD
was significant (β = .21, p < .05), controlling for Time 1 GDD. In order to assess for possible
mediation effects, the hypothesized structural model depicting the relationship between Time 1
SC perfectionism, Time 1 GDD, Month 6 and Year 3 stress-sadness reactivity, and Year 4 GDD
was tested (Figure 1). The hypothesized structural model had the following acceptable fit
39
indices: χ2 (2, N=150) = 2.74, ns; IFI = .99; CFI, = .99; RMSEA = .05; AIC = 28.74; and BIC =
67.88. Next, to evaluate whether the relation between Time 1 SC perfectionism and Year 4
GDD was fully mediated by stress-sadness reactivity, a partially mediated model (which
included a path between Time 1 SC perfectionism and Year 4 GDD) was compared to the
hypothesized fully mediated model. The chi-square difference test,Δχ²(1, N = 150) = 2.73, ns,
and the BIC values (70.16 for the partially mediated model) but not the AIC values (28.01 for the
partially mediated model) favored the fully mediated model, and the path between Time 1 SC
perfectionism and Year 4 GDD was nonsignificant (β = .14). Thus, the fully mediated model was
retained.
The statistically significant mediated effects demonstrated that the relationship between
Time 1 SC perfectionism and Year 4 GDD was fully mediated by Month 6 and Year 3 stresssadness reactivity. Specifically, as shown in Figure 2 and Table 2, SC perfectionism was
indirectly related to Year 4 GDD through (a) Month 6 and Year 3 stress-sadness reactivity as two
sequential mediators and (b) Year 3 stress-sadness reactivity as a single mediator. Time 1 GDD
was also significantly indirectly related to Year 4 GDD through Year 3 stress-sadness reactivity.
SC perfectionism, stress-sadness reactivity, and anhedonic depression model. As
seen in Figure 3, the total effect between Time 1 SC perfectionism and Year 4 AD was
significant (β = .24, p < .01), controlling for Time 1 AD symptoms. Given that the total effects
were significant, the possibility of mediation existed. The hypothesized model predicting Year 4
AD (see Figure 1) was tested, and had the following acceptable fit indices: χ2 (2, N=150) = 4.38,
ns; IFI = .98; CFI = .98; RMSEA = .09; AIC = 30.38; and BIC = 69.52. Next, to evaluate
whether the relation between Time 1 SC perfectionism and Year 4 AD was fully mediated by
stress-sadness reactivity, a partially mediated model (which included a path between Time 1 SC
40
perfectionism and Year 4 AD) was compared to the hypothesized fully mediated model. The
chi-square difference test, Δχ²(1, N = 150) = 3.82, ns, and the BIC values (70.71 for the partially
mediated model) but not the AIC values (28.56 for the partially mediated model) favored the
fully mediated model. Further, although the path from Time 1 SC to Year 4 AD was significant
(β = .18, p < .05), the Year 3 stress-sadness reactivity to Year 4 AD relation became
nonsignificant (β = .14, p < .10) in the partially mediated model. As the partially mediated
model was not theoretically informative in explaining why SC perfectionism was related to Year
4 AD, we retained the fully mediated model, which had an essentially equivalent fit to the data,
was more parsimonious, and had greater explanatory value.
The relation between Time 1 SC perfectionism and Year 4 AD was significantly
mediated by stress-sadness reactivity. As shown in Figure 3 and Table 2, SC perfectionism was
indirectly related to Year 4 AD through (a) Month 6 and Year 3 stress-sadness reactivity as two
sequential mediators and (b) Year 3 stress-sadness reactivity as a single mediator.
SC perfectionism, stress-sadness reactivity, and general anxious symptoms model.
As seen in Figure 4, the total effect between Time 1 SC perfectionism and Year 4 GDA,
controlling for Time 1 GDA, was nonsignificant (β = .11). Given that Time 1 SC perfectionism
was not directly related to Year 4 GDA, the possibility of an indirect effect was considered. The
hypothesized structural model predicting Year 4 GDA (see Figure 1) was tested and had the
following acceptable fit indices: χ2 (2, N=150) = .26, ns; IFI = 1.01; CFI = 1.00; RMSEA = .00;
AIC = 26.26; and BIC = 65.40. Next, the partially mediated model that included a path between
Time 1 SC perfectionism and Year 4 GDA did not fit the data significantly better than the fully
mediated model, according to the chi-square difference test, Δχ²(1, N = 150) = .10, ns, and the
AIC and BIC values (28.17 and 70.71, respectively, for the partially mediated model), and the
41
path between Time 1 SC and Year 4 GDA was nonsignificant (β = .03). Therefore, the
hypothesized, fully mediated model was retained.
Time 1 SC perfectionism was significantly indirectly related to Year 4 GDA through
Month 6 and Year 3 stress-sadness reactivity. More precisely, Figure 4 and Table 2 demonstrates
that Time 1 SC perfectionism was indirectly related to Year 4 GDA symptoms through (a)
Month 6 and Year 3 stress-sadness reactivity as two sequential mediators and (b) Year 3 stresssadness reactivity as a single mediator. Time 1 GDA was also significantly indirectly related to
Year 4 GDA through Month 6 and Year 3 stress-sadness reactivity as two sequential mediators.
SC perfectionism, stress-sadness reactivity, and anxious arousal model. Total effects
between Time 1 SC perfectionism and Year 4 AA, controlling for Time 1 AA, were
nonsignificant (β = .10). In order to assess for indirect effects, the hypothesized model (Figure 1)
between Time 1 SC perfectionism and Year 4 AA was tested and had the following acceptable fit
indices: χ2 (2, N=150) = 1.28, ns; IFI = 1.01; CFI = 1.00; and RMSEA = .00. The relationship
between Year 3 stress-sadness reactivity and Year 4 GDA was nonsignificant. Thus, it was only
through shared variance with Time 1 AA that the link between Time 1 SC perfectionism and
Year 4 AA was explained.
Supplementary Path Analyses with Stress-Negative Affect Reactivity
In order to compare the mediating role of stress-sadness reactivity versus stress-NA
reactivity in the relation between SC perfectionism and depressive/anxious symptoms over time,
the same path analyses and tests of indirect effects described above were conducted using stressNA reactivity instead of stress-sadness reactivity in the GDD/AD/GDA/AA models (see Figure
1). Consistent with the stress-sadness reactivity mediation effects, SC perfectionism was found
to be indirectly related to each of Year 4 GDD and Year 4 GDA, but not Year 4 AA, through
42
Month 6 and Year 3 stress-NA reactivity. In contrast to stress-sadness reactivity, however, Year
4 stress-NA reactivity was not significantly related to Year 4 AD (β = .14, p < .10), and did not
mediate the relation between SC perfectionism and Year 4 AD, when controlling for Time 1 AD.
Supplementary Path Analyses with Aggregated Daily Event Stress
In order to evaluate whether mean levels of stress mediated the relationship between
Time 1 SC perfectionism and Year 4 GDD/AD/GDA/AA outcomes as compared to stress
reactivity, the same path analyses and tests of indirect effects described above were conducted
using aggregated daily event stress instead of stress reactivity in the GDD/AD/GDA/AA models
(see Figure 1). In contrast to the stress reactivity mediation effects, SC perfectionism was not
significantly related to either Month 6 or Year 3 aggregated stress, and was not indirectly related
to each of Year 4 GDD, GDA, and AA through Month 6 and Year 3 aggregated stress, when
controlling for Time 1 GDD, GDA, and AA, respectively. In addition, Year 3 aggregated stress
was not significantly related to Year 4 AD (β = .12, p > .10), and did not mediate the relation
between SC perfectionism and Year 4 AD, when controlling for Time 1 AD.
Discussion
The present study enhances longitudinal explanatory conceptualizations that can be used
to help both therapists and self-critical perfectionistic clients better understand the role that
enduring stress reactivity plays in these clients’ vulnerability to distress symptoms over time.
These findings extend recent research (Dunkley, Mandel, et al., 2014; Dunkley, Ma, et al. 2014)
by using repeated sequences of daily dairies to create individual stress reactivity slopes to
identify stress reactivity as a stable explanatory mechanism in the relationship between SC
perfectionism and depressive and anxious symptoms over four years.
43
SC Perfectionism and Future Depression and Anxiety
Our results showed that high SC perfectionism was directly related to both general
depressive symptoms (e.g., guilt, anger, sadness) as well as anhedonic depressive symptoms
(e.g., low energy/interest, lack of pleasure) over a period of four years when controlling for
baseline symptoms. These findings are consistent with several previous studies that found SC
perfectionism to be a predictor of depressive symptoms over time (J. R. Cohen, Young, Hankin,
Yao, Zhu & Abela 2013; Dunkley, Sanislow et al. 2006, 2009; Sherry et al., 2014), and extend
these previous findings by testing this relationship in community adults over a period as long as
four years. On the other hand, SC perfectionism was not directly related to either general anxious
distress (e.g., unease, worry) or specific anxious arousal (e.g., trembling, feeling faint, difficulty
breathing) over four years when controlling for baseline symptoms. These findings are in line
with recent research that found no direct relation between SC perfectionism and anxious
symptoms over time (J. R. Cohen et al., 2013; Sherry et al., 2014). However, these results are in
contrast to several studies that have found SC perfectionism to be directly related to the onset of
anxious symptoms (see Egan et al., 2011; Einstein, Lovibond, & Gaston, 2000). To explore this
further, even though SC perfectionism was not directly related to anxious distress, we examined
the possibility that SC perfectionism indirectly contributed to the development of general and
specific anxious symptoms through stress reactivity over time.
SC Perfectionism and Depressive and Anxious Symptoms over Four Years: The Mediating
Role of Enduring Stress Reactivity
Our assessment of stress reactivity considerably advanced previous studies that used
one-time questionnaires (Aldea & Rice, 2006) by utilizing repeated sequences of daily dairies
and multilevel modeling in order to develop strength-of-relation variables that represent the
44
relationship between stress appraisals and both sadness and negative affect at Month 6 and Year
3. Our method of analysis allowed for the creation of an individual slope that accounted for each
participant’s unique relationship between stress and affect over time, which was then used in our
subsequent path analyses as a mediator explaining the relationship between SC perfectionism
and distress symptoms four years later. This novel method is considered to be an important
advancement over past techniques, which have used multilevel modeling to observe how a single
variable (e.g., affect) varies within an individual (Cole et al., 2014; Sterba, 2014), but have
focused less on the relationship between two variables (e.g., stress and affect) within an
individual over time. The present study was the first to test the mediational role of this withinperson slope in the relation between SC perfectionists and distress symptoms over time.
We found that aggregated daily stress exhibited higher levels of stability than stress
reactivity between Month 6 and Year 3, which is in keeping with the suggestion that stress
reactivity is inherently more likely to change over time than mean levels of daily stress (see Cole
et al., 2014; Sliwinski et al., 2009). At the same time, our current findings demonstrated the
enduring effects of stress reactivity, such that high SC perfectionism was indirectly related to
Year 3 stress reactivity through Month 6 stress reactivity. These findings can be explained by
theory suggesting that dysfunctional self-worth contingencies develop in response to conditional
parental approval that is dependent on achieving unrealistic standards, and that these
contingencies continue into adulthood for SC perfectionists (Blatt, 1995).
SC perfectionism, stress-sadness reactivity, and depressive symptoms. Our study
built substantially on previous findings showing that stress reactivity prospectively predicts
depressive outcomes (L. H. Cohen et al., 2005) by identifying enduring stress-sadness reactivity
as a mediator explaining the relationship between SC perfectionism and depressive symptoms
45
over a period of four years. A noteworthy strength of the present study was the inclusion of two
separate depressive outcomes, which provided a compelling demonstration of the impact of
longstanding stress-sadness reactivity across distinct aspects of depressive symptomatology for
SC perfectionistic individuals. Our findings demonstrated that persistent stress-sadness reactivity
explains the relationship between high SC perfectionism and general depressive symptoms (see
Figure 2) as well as specific anhedonic depressive features (see Figure 3) over a period of four
years. These results extend the perfectionism diathesis-stress model (Dunkley, Mandel, & Ma,
2014; Enns et al. 2005) by showing that individuals with higher SC perfectionism have an
enduring heightened reactivity to stress, which in turn contributes to their vulnerability to various
depressive symptoms over time.
SC perfectionism, stress-sadness reactivity, and anxious symptoms. The finding that
SC perfectionism was not directly related to anxious symptoms relatively far into the future (four
years) is consistent with the observation that the size of a distal effect typically gets smaller
because it becomes more likely that it is affected by competing and/or random factors (see
Shrout & Bolger, 2002). Our findings supported the contention that studying indirect effects in
such cases can still be conceptually informative. SC perfectionism was indirectly related to
general anxious distress four years later via stable stress-sadness reactivity (see Figure 4),
whereas longstanding stress-sadness reactivity did not indirectly explain the relationship between
SC perfectionism and specific anxious arousal. This suggests that high SC perfectionists
experience subclinical symptoms of anxiety such as nervousness and worry because they are
consistently emotionally reactive to stress. However, stress reactivity might not explain the
relationship between SC perfectionism and physical symptoms of anxious arousal. Recent
research has suggested that SC perfectionism and anxiety co-occur but that SC perfectionism is
46
not a predictor of anxiety (Sherry et al., 2014). Our findings demonstrate a more nuanced
understanding of this relationship, whereby SC perfectionism was indirectly related to anxious
symptoms that are often found to be comorbid with depressive symptoms via enduring stress
reactivity. These results also support the notion that sadness may elicit a feeling of loss of
control, which may contribute to anxious symptoms over time as well (Liverant, Brown, Barlow,
& Roemer, 2008; Taylor & Rachman, 1991).
Stress-Negative Affect Reactivity as an Alternative Mediator. Similar to stresssadness reactivity, daily stress-NA reactivity mediated the relation between SC perfectionism
and general depressive and anxious symptoms over four years. On the other hand, the present
study highlighted an important distinction between stress-sadness reactivity and stress-NA
reactivity in that stress-NA reactivity did not mediate the association between SC perfectionism
and anhedonic depressive symptoms over time. These findings further support the contention
that general and specific symptoms are distinguishable and worthy of investigation (Clark &
Watson, 1991). Moreover, we demonstrated that responding to daily stress with sadness, as
opposed to negative affect, has additional detrimental implications for individuals higher on SC
perfectionism. This finding is in line with suggestions that negative affect may lead to more
active behaviours that are associated with coping with stress, whereas sadness may trigger more
of a helplessness orientation that leads individuals to disengage, which contributes to increases in
a range of depressive symptoms over time (see Carver & Harmon-Jones, 2009).
Taken together, our stress-sadness and stress-NA reactivity findings demonstrated how
SC perfectionism is a transdiagnostic risk factor for shared general depressive and anxious
symptoms via stress reactivity. This is congruent with Clark and Watson’s (1991) Tripartite
model, which posits that there is significant overlap between the general depressive and general
47
anxious symptoms subscales. By understanding explanatory processes (i.e. stress reactivity) that
cut across both of these emotional distress symptoms, we are better suited to help alleviate
symptoms in individuals who exhibit mixed and below threshold anxiety and depression (Ellard,
Fairholme, Boisseau, Farchione, & Barlow, 2010). In addition, the fact that stress reactivity
remains stable over time and mediates the relationship between SC perfectionism and
transdiagnostic symptoms suggests that stress reactivity may serve as a particularly important
intervention target for SC perfectionists.
Aggregated Daily Stress as an Alternative Mediator. The present findings also
distinguished daily stress reactivity from aggregated daily stress. Although previous research has
found that perceived stress explains the relationship between SC perfectionism and negative
outcomes (Chang, 2006; Dunkley et al. 2003), our findings revealed that average levels of stress
did not explain the relation between SC perfectionism and depressive and anxious symptoms
four years later. This finding is in line with and further extends Beck’s theory (e.g., 1979)
suggesting that how one typically reacts to an appraisal, as opposed to the appraisal itself, better
explains vulnerability to depressive and anxious symptoms over time.
Clinical Implications
The implications of our results to clinical practice are critical, given that research has
shown that high SC perfectionists have demonstrated a poor response to treatment targeting
mood and anxiety difficulties (Blatt & Zuroff, 2005; Jacobs et al., 2009; Shahar, Blatt, Zuroff,
Krupnick, & Sotsky, 2004). Our findings highlight the relevance of targeting daily stress
reactivity in highly SC perfectionistic individuals in order to reduce general and specific
depressive as well as general anxious symptoms several years later. Importantly, our research
suggests that focusing on stress reactivity may be more advantageous than helping a client to
48
reduce their average levels of stress. Given that stress reactivity is inherently less stable than
average stress levels (Singer, 2013; Sliwinski et al., 2009), it may represent a more malleable
treatment target. Furthermore, even small shifts in the form of affective response, such as
shifting from sadness to negative affect, may provide some relief for highly SC individuals in
preventing the development of anhedonia.
In terms of treating stress reactivity, research has shown that cognitive and behavioural
techniques can improve emotional reactivity by targeting unhelpful thoughts and behaviours
surrounding an individuals’ response to daily stress. This method focuses on cognitively
restructuring errors in overemphasizing the negative impact of stressors, which then leads clients
to exhibit better emotional control (Niles, Mesri, Burklund, Lieberman, & Craske, 2013). In
addition, research has demonstrated that maladaptive appraisals (i.e., perceived criticism, lower
perceived control) and avoidant coping contribute to increases in stress appraisals (Dunkley, Ma,
et al., 2014); therefore, targeting these triggers may help to reduce stress and, by extension,
sadness. Lastly, therapy that incorporates acceptance and mindfulness techniques offers
strategies for better distancing from and accepting ones’ emotions, which helps clients to react
less negatively when faced with stress (Hayes, Strosahl, & Wilson, 2012; Niles et al., 2013).
Limitations and Directions for Future Research
Although our current research had several strengths, such as the four year-longitudinal
design and the use of repeated daily diaries to derive stress reactivity slopes, the present study
had some limitations. As participants completed the daily diaries using paper and pencil, the
replicability of our findings using electronic diaries should be examined. In addition, as the
present findings are based on self-report measures, future research should confirm our findings
with more objective data collection measures. For instance, Richardson, Rice, and Devine (2014)
49
assessed cortisol as a marker for stress response in perfectionists and recent studies have
incorporated functional magnetic resonance imaging (fMRI) measurements to observe an
individual’s response to negative stimuli (Gray et al., 2012). Both of these measures offer
alternative and complimentary methods of observation, and may be useful in conjunction with
daily diaries in the future. Another limitation of the present study was that the predictor,
mediator, and outcome were not assessed at all time points, which precludes stronger causal
statements (see Cole & Maxwell, 2003). Future studies should also evaluate the generalizability
of our findings in clinical and other nonclinical populations. Furthermore, dysfunctional selfworth contingencies are theorized to be an important aspect of SC perfectionists’ vulnerability to
stress. Therefore, future research should include measures of self-worth contingencies in order to
further clarify this relationship. Lastly, an important direction for future research is to develop
and test specific stress reactivity interventions in order to determine whether they help to prevent
the onset of depressive and anxious distress for SC perfectionists over the long term.
Conclusion
The present study used a repeated daily diary design and individual stress reactivity
slopes to better understand the relationship between SC perfectionism and distress symptoms
over the longer-term. Our findings can help therapists and SC perfectionistic clients to develop a
better understanding of what contributes to these clients’ vulnerability to depressive and anxious
symptoms over time. The current study demonstrates that enduring stress reactivity, relative to
average levels of stress, is an important longitudinal explanatory mediator in the relationship
between high SC perfectionism and depressive and anxious distress over four years, which may
allow for more targeted and effective intervention strategies in the future.
50
References for Article 1
Akaike, H. (1987). Factor analysis and AIC. Psychometrika, 52, 317-332. doi:
10.1007/BF02294359
Aldea, M. A., & Rice, K. G. (2006). The role of emotional dysregulation in perfectionism and
psychological distress. Journal of Counseling Psychology, 53, 498-510. doi:
10.1037/0022-0167.53.4.498
American Psychology Association. (2014). Stress in America: Paying with our health [Press
release]. Retrieved from http://www.apa.org/news/press/releases/stress/2014/stressreport.pdf
Arbuckle, J. L. (2003). Amos Users’ Guide Version 5.0. Chicago: Small Waters Corporation.
Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S.,
& Simonich, H. (2007). Perfectionism and eating disorders: Current status and future
directions. Clinical Psychology Review, 27, 384-405. doi: 10.1016/j.cpr.2006.12.005
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford Press.
Bentler, P. M., & Chou, C.-P. (1987). Practical issues in structural modeling. Sociological
Methods & Research, 16, 78-117. doi: 10.1177/0049124187016001004
Blatt, S. J. (1995). The destructiveness of perfectionism: Implications for the treatment of
depression. American Psychologist, 50, 1003-1020. doi: 10.1037/0003-066x.50.12.1003
Blatt, S. J., D'Afflitti, J. P., & Quinlan, D. M. (1976). Experiences of depression in normal young
adults. Journal of Abnormal Psychology, 85, 383-389. doi: 10.1037/0021-843X.85.4.383
51
Blatt, S. J., & Zuroff, D. C. (2005). Empirical evaluation of the assumptions in identifying
evidence based treatments in mental health. Clinical Psychology Review, 25, 459-486.
doi: 10.1016/j.cpr.2005.03.001
Carver, C. S., & Harmon-Jones, E. (2009). Anger is an approach-related affect: Evidence and
implications. Psychological Bulletin, 135, 183-204. doi: 10.1037/a0013965
Chang, E.C. (2006). Perfectionism and dimensions of psychological well-being in a college
student sample: A test of a stress-mediation model. Journal of Social and Clinical
Psychology, 25, 1001-1022. doi: 10.1521/jscp.2006.25.9.1001
Chang, E. C., & Rand, K. L. (2000). Perfectionism as a predictor of subsequent adjustment:
Evidence for a specific diathesis-stress mechanism among college students. Journal of
Counseling Psychology, 47, 129-137. doi: 10.1037/0022-0167.47.1.129
Charles, S. T., Piazza, J. R., Mogle, J., Sliwinski, M. J., & Almeida, D. M. (2013). The wear and
tear of daily stressors on mental health. Psychological Science, 24, 733-741. doi:
10.1177/0956797612462222
Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric
evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316-336.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155-159. doi: 10.1037/00332909.112.1.155
Cohen, J. R., Young, J.F., Hankin, B.L., Yao, S., Zhu, X.Z., & Abela, J.R.Z. (2013). Personality
predispositions in Chinese adolescents: The relation between self-criticism, dependency,
and prospective internalizing symptoms. Journal of Social and Clinical Psychology, 32,
596-618. doi: 10.1521/jscp.2013.32.6.596
52
Cohen, L. H., Gunthert, K. C., Butler, A. C., O'Neill, S. C., & Tolpin, L. H. (2005). Daily
affective reactivity as a prospective predictor of depressive symptoms. Journal of
Personality, 73, 1687-1713. doi: 10.1111/j.0022-3506.2005.00363.x
Cole, D. A., Martin, N. C., Sterba, S. K., Sinclair-McBride, K., Roeder, K. M., Zelkowitz, R., &
Bilsky, S. A. (2014). Peer victimization (and harsh parenting) as developmental
correlates of cognitive reactivity, a diathesis for depression. Journal of Abnormal
Psychology, 123, 336-349. doi: 10.1037/a0036489
Cole, D. A., Maxwell, S. E. (2003). Testing mediational models with longitudinal data:
Questions and tips in the use of structural equation modeling. Journal of Abnormal
Psychology, 112, 558-577. doi: 10.1037/0021-843x.112.4.558
Cranford, J. A., Shrout, P. E., Iida, M. , Rafaeli, E. , Yip, T., & Bolger, N. (2006). A procedure
for evaluating sensitivity to within-person change: Can mood measures in diary studies
detect change reliably? Personality and Social Psychology Bulletin, 32, 917-929. doi:
10.1177/0146167206287721
Dunkley, D. M., Berg, J. L., & Zuroff, D. C. (2012). The role of perfectionism in daily selfesteem, attachment, and negative affect. Journal of Personality, 80, 633-663. doi:
10.1111/j.1467-6494.2011.00741.x
Dunkley, D. M., Blankstein, K. R., & Berg, J. L. (2012). Perfectionism dimensions and the fivefactor model of personality. European Journal of Personality, 26, 233-244. doi:
10.1002/per.829
Dunkley, D. M., Blankstein, K. R., Masheb, R. M., & Grilo, C. M. (2006). Personal standards
and evaluative concerns dimensions of "clinical" perfectionism: A reply to Shafran et al.
53
(2002, 2003) and Hewitt et al. (2003). Behavioural Research and Therapy, 44, 63-84.
doi: 10.1016/j.brat.2004.12.004
Dunkley, D. M., & Kyparissis, A. (2008). What is DAS self-critical perfectionism really
measuring? Relations with the five-factor model of personality and depressive symptoms.
Personality and Individual Differences, 44, 1295-1305. doi: 10.1016/j.paid.2007.11.022
Dunkley, D. M., Ma, D., Lee, I. A., Preacher, K. J., & Zuroff, D. C. (2014). Advancing complex
explanatory conceptualizations of daily negative and positive affect: Trigger and
maintenance coping action patterns. Journal of Counseling Psychology, 61, 93-109. doi:
10.1037/a0034673
Dunkley, D. M., Mandel, T., & Ma, D. (2014). Perfectionism, neuroticism, and daily stress
reactivity and coping effectiveness 6 months and 3 years later. Journal of Counseling
Psychology, 61, 616-633. doi: 10.1037/cou0000036
Dunkley, D. M., Sanislow, C. A., Grilo, C. M., & McGlashan, T. H. (2006). Perfectionism and
depressive symptoms 3 years later: Negative social interactions, avoidant coping, and
perceived social support as mediators. Comprehensive Psychiatry, 47, 106-115. doi:
10.1016/j.comppsych.2005.06.003
Dunkley, D. M., Sanislow, C. A., Grilo, C. M., & McGlashan, T. H. (2009). Self-criticism versus
neuroticism in predicting depression and psychosocial impairment for 4 years in a clinical
sample. Comprehensive Psychiatry, 50, 335-346. doi: 10.1016/j.comppsych.2008.09.004
Dunkley, D. M., Zuroff, D. C., & Blankstein, K. R. (2003). Self-critical perfectionism and daily
affect: Dispositional and situational influences on stress and coping. Journal of
Personality and Social Psychology, 84, 234-252. doi: 10.1037//0022-3514.84.1.234
54
Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A
clinical review. Clinical Psychology Review, 31, 203-212. doi: 10.1016/j.cpr.2010.04.009
Einstein, D. A., Lovibond, P. F., & Gaston, J. E. (2000). Relationship between perfectionism and
emotional symptoms in an adolescent sample. Australian Journal of Psychology, 52, 8993. doi: 10.1080/00049530008255373
Ellard, K. K., Fairholme, C. P., Boisseau, C. L., Farchione, T. J., & Barlow, D. H. (2010).
Unified protocol for the transdiagnostic treatment of emotional disorders: Protocol
development and initial outcome data. Cognitive and Behavioral Practice, 17, 88-101.
doi: 10.1016/j.cbpra.2009.06.002
Enns, M. W., Cox, B. J., & Clara, I. (2002). Adaptive and maladaptive perfectionism:
Developmental origins and association with depression proneness. Personality and
Individual Differences, 33, 921-935. doi: 10.1016/S0191-8869(01)00202-1
Enns, M. W., Cox, B. J., & Clara, I. P. (2005). Perfectionism and neuroticism: A longitudinal
study of specific vulnerability and diathesis-stress models. Cognitive Therapy and
Research, 29, 463-478. doi: 10.1007/s10608-005-2843-04
Flett, G. L., & Hewitt, P. L. (Eds.). (2002). Perfectionism: Theory, research, and treatment.
Washington, DC: American Psychological Association. doi: 10.1037/10458-000
Flett, G. L., Hewitt, P., Blankstein, K., & Mosher, S. (1995). Perfectionism, life events, and
depressive symptoms: A test of a diathesis-stress model. Current Psychology, 14, 112137. doi: 10.1007/bf02686885
Flett, G. L., Hewitt, P. L., Oliver, J.M., & Macdonald, S. (2002). Perfectionism in children and
their parents: A developmental analysis. In G. L. Flett & P. L. Hewitt (Eds.),
55
Perfectionism: Theory, research, and treatment (pp. 89-132): Washington, DC:
American Psychological Association. doi: 10.1037/10458-004
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism.
Cognitive Therapy and Research, 14, 449-468. doi: 10.1007/bf01172967
Gray, M. A., Beacher, F. D., Minati, L., Nagai, Y., Kemp, A. H., Harrison, N. A., & Critchley,
H. D. (2012). Emotional appraisal is influenced by cardiac afferent information. Emotion,
12, 180-191. doi: 10.1037/a0025083
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The
process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.
Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts:
Conceptualization, assessment, and association with psychopathology. Journal of
Personality and Social Psychology, 60, 456-470. doi: 10.1037/0022-3514.60.3.456
Hewitt, P. L., & Flett, G. L. (2002). Perfectionism and stress processes in psychopathology. In G.
L. Flett & P. L. Hewitt (Eds.), Perfectionism: Theory, research, and treatment (pp. 255–
284). Washington, DC: American Psychological Association.
Hewitt, P. L., Flett, G. L., Turnbull-Donovan, W., & Mikail, S. F. (1991). The Multidimensional
Perfectionism Scale: Reliability, validity, and psychometric properties in psychiatric
samples. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3,
464-468. doi: 10.1037/1040-3590.3.3.464
Holmbeck, G. N. (1997). Toward terminological, conceptual, and statistical clarity in the study
of mediators and moderators: Examples from the child-clinical and pediatric psychology
literatures. Journal of Consulting and Clinical Psychology, 65, 599-610. doi:
10.1037/0022-006X.65.4.599
56
Hoyle, R. H., & Panter, A. T. (1995). Writing about structural equation models. In R. H. Hoyle
(Ed.), Structural equation modeling: Concepts, issues, and applications (pp. 158-176):
Thousand Oaks, CA: Sage Publications, Inc.
Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis:
Conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1-55. doi:
10.1080/10705519909540118
Jacobs, R. H., Silva, S. G., Reinecke, M. A., Curry, J. F., Ginsburg, G. S., Kratochvil, C. J., &
March, J. S. (2009). Dysfunctional attitudes scale perfectionism: A predictor and partial
mediator of acute treatment outcome among clinically depressed adolescents. Journal of
Clinical Child and Adolescent Psychology, 38, 803-813. doi:
10.1080/15374410903259031
Kannan, D., & Levitt, H. M. (2013). A review of client self-criticism in psychotherapy. Journal
of Psychotherapy Integration, 23, 166-178. doi: 10.1037/a0032355
Klein, R. B. (2005). Principles and practice of structural equation modeling (2nd ed.). New
York, NY: Guilford Press.
Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization:
Working effectively with clients in cognitive-behavioral therapy. New York: Guilford
Press.
Lindebaum, D., & Jordan, P. J. (2014). When it can be good to feel bad, and bad to feel good –
Exploring asymmetries in workplace emotional outcomes. Human Relations, 66, 1-14.
doi: 10.1177/0018726712474403
Liverant, G. I., Brown, T. A., Barlow, D. H., & Roemer, L. (2008). Emotion regulation in
unipolar depression: The effects of acceptance and suppression of subjective emotional
57
experience on the intensity and duration of sadness and negative affect. Behaviour
Research and Therapy, 46, 1201-1209. doi: 10.1016/j.brat.2008.08.001
MacKinnon, D. P., Lockwood, C. M., & Williams, J. (2004). Confidence limits for the indirect
effect: Distribution of the product and resampling methods. Multivariate Behavioral
Research, 39, 99-128. doi: 10.1207/s15327906mbr3901_4
McCrae, R. R., & Costa, P. T., Jr. (2008). The five-factor theory of personality. In O. P. John, R.
W. Robins, and L. A. Pervin (Eds.), Handbook of personality: Theory and research (3rd
ed.). New York, NY: Guilford.
Niles, A. N., Mesri, B., Burklund, L. J., Lieberman, M. D., & Craske, M. G. (2013). Attentional
bias and emotional reactivity as predictors and moderators of behavioral treatment for
social phobia. Behaviour Research and Therapy, 51, 669-679. doi:
10.1016/j.brat.2013.06.005
O'Neill, S. C., Cohen, L. H., Tolpin, L. H., & Gunthert, K. C. (2004). Affective reactivity to
daily interpersonal stressors as a prospective predictor of depressive symptoms. Journal
of Social and Clinical Psychology, 23, 172-194. doi: 10.1521/jscp.23.2.172.31015
Powers, T. A., Zuroff, D. C., & Topciu, R. A. (2004). Covert and overt expressions of selfcriticism and perfectionism and their relation to depression. European Journal of
Personality, 18, 61-72. doi: 10.1002/per.499
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and
comparing indirect effects in multiple mediator models. Behavior Research Methods, 40,
879-891. doi: 10.3758/BRM.40.3.879
58
Preacher, K. J., & Selig, J. P. (2012). Advantages of Monte Carlo confidence intervals for
indirect effects. Communication Methods and Measures, 6, 77-98. doi:
10.1080/19312458.2012.679848
Reidy, J., & Keogh, E. (1997). Testing the discriminant and convergent validity of the mood and
anxiety symptoms questionnaire using a British sample. Personality and Individual
Differences, 23, 337-344. doi: 10.1016/S0191-8869(97)00048-2
Rice, K. G., Leever, B. A., Christopher, J., & Porter, J. D. (2006). Perfectionism, stress, and
social (dis)connection: A short-term study of hopelessness, depression, and academic
adjustment among honors students. Journal of Counseling Psychology, 53, 524-534. doi:
10.1037/0022-0167.53.4.524
Richardson, C. M., Rice, K. G., & Devine, D. P. (2014). Perfectionism, emotion regulation, and
the cortisol stress response. Journal of Counseling Psychology, 61, 110-118. doi:
10.1037/a0034446
Schlomer, G. L., Bauman, S., & Card, N. A. (2010). Best practices for missing data management
in counseling psychology. Journal of Counseling Psychology, 57, 1-10. doi:
10.1037/a0018082
Schwarz, G. (1978). Estimating the dimension of a model. The Annals of Statistics, 6, 461-464.
doi: 10.1214/aos/1176344136
Selig, J. P., & Preacher, K. J. (2008, June). Monte Carlo method for assessing mediation: An
interactive tool for creating confidence intervals for indirect effects [Computer software].
Retrieved from http://quantpsy.org/.
59
Shahar, G., Blatt, S., Zuroff, D., Krupnick, J.L., & Sotsky, S.M. (2004). Perfectionism impedes
social relations and response to brief treatment for depression. Journal of Social and
Clinical Psychology, 23, 140-154. doi: 10.1521/jscp.23.2.140.31017
Sherry, S. B., Richards, J. E., Sherry, D. L., & Stewart, S. H. (2014). Self-critical perfectionism
is a vulnerability factor for depression but not anxiety: A 12-month, 3-wave longitudinal
study. Journal of Research in Personality, 52, 1-5. doi: 10.1016/j.jrp.2014.05.004
Shrout, P. E., & Bolger, N. (2002). Mediation in experimental and nonexperimental studies: New
procedures and recommendations. Psychological Methods, 7, 422-445. doi:
10.1037//1082-989x.7.4.422
Singer, J. A. (2013). Lost in translation? Finding the person in the emerging paradigm of clinical
science: Introduction to a special issue on personality psychology and psychotherapy.
Journal of Personality, 81, 511-514. doi: 10.1111/jopy.12017
Slaney, R. B., Rice, K. G., Mobley, M., Trippi, J., & Ashby, J. S. (2001). The revised almost
perfect scale. Measurement and Evaluation in Counseling and Development, 34, 130145.
Sliwinski, M. J., Almeida, D. M., Smyth, J., & Stawski, R. S. (2009). Intraindividual change and
variability in daily stress processes: Findings from two measurement-burst diary studies.
Psychology and Aging, 24, 828-840. doi: 10.1037/a0017925
Sterba, S. (2014). Modeling strategies in developmental psychopathology research: Prediction of
individual change. In M. Lewis & K. D. Rudolph (Eds.), Handbook of developmental
psychopathology (pp. 109-124): Springer US.
60
Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches, evidence,
challenges. Personality and Social Psychology Review, 10, 295-319. doi:
10.1207/s15327957pspr1004_2
Taylor, S. T., & Rachman, S. J. (1991). Fear of sadness. Journal of Anxiety Disorders, 5, 375381. doi: 10.1016/0887-6185(91)90037-T
Tong, E. M. W. (2010). Personality influences in appraisal–emotion relationships: The role of
neuroticism. Journal of Personality, 78, 393-417. doi: 10.1111/j.1467-6494.2010.00620.x
Watson, D. (2009). Differentiating the Mood and Anxiety Disorders: A Quadripartite Model.
Annual Review of Clinical Psychology, 5, 221-247. doi:
10.1146/annurev.clinpsy.032408.153510
Watson, D., & Clark, L. A. (1991). The Mood and Anxiety Symptom Questionnaire. Department
of Psychology. University of Iowa.
Watson, D., & Clark, L. A. (1994). The PANAS–X: Manual for the Positive and Negative Affect
Schedule–expanded form. Iowa City: University of Iowa.
Watson, D., Clark, L. A., & Stasik, S. M. (2011). Emotions and the emotional disorders: A
quantitative hierarchical perspective. International Journal of Clinical and Health
Psychology, 11, 429-442.
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures
of positive and negative affect: The PANAS scales. Journal of Personality and Social
Psychology, 54, 1063–1070. doi: 10.1037/0022-3514.54.6.1063
Watson, D., Weber, K., Assenheimer, J. S., Clark, L. A., Strauss, M. E., & McCormick, R. A.
(1995). Testing a tripartite model: I. Evaluating the convergent and discriminant validity
61
of anxiety and depression symptom scales. Journal of Abnormal Psychology, 104, 3-14.
doi: 10.1037/0021-843X.104.1.3
Weissman, A. N., & Beck, A. T. (1978). Development and validation of the Dysfunctional
Attitude Scale: A preliminary investigation. Paper presented at the 62nd Annual Meeting
of the American Educational Research Association, Toronto, Ontario, Canada.
Wichers, M., Geschwind, N., Jacobs, N., Kenis, G., Peeters, F., Derom, C., . . . van Os, J. (2009).
Transition from stress sensitivity to a depressive state: Longitudinal twin study. The
British Journal of Psychiatry, 195, 498-503. doi: 10.1192/bjp.bp.108.056853
Zuroff, D. C., Mongrain, M., & Santor, D. A. (2004). Conceptualizing and measuring personality
vulnerability to depression: Comment on Coyne and Whiffen (1995). Psychological
Bulletin, 130, 489-511. doi: 10.1037/0033-2909.130.3.489
62
Table 1
Intercorrelations, Means, Standard Deviations, and Internal Consistencies of the Perfectionism, Stress Reactivity, Aggregated Stress, and
Depressive and Anxious Symptoms Measures
Variables
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1. T1 Self Crit.
2. T1 GDD
3. T1 AD
4. T1 GDA
5. T1 AA
6. M6 SR SAD
7. M6 SR NA
8. M6 Agg St.
9.Y3 SR SAD
10. Y3 SR NA
11. Y3 Agg St.
12. Y4 GDD
13. Y4 AD
14. Y4 GDA
15. Y4 AA
M
SD
.79
.62***
.52***
.48***
.48***
.42***
.41***
.27***
.45***
.31***
.32***
.48***
.35***
.34***
.35***
.00
.83
.92
.62***
.64***
.63***
.37***
.45***
.29***
.46***
.42***
.32***
.56***
.35***
.31***
.34***
23.15
8.84
.91
.33***
.34***
.26**
.22**
.17*
.33***
.12
.20*
.31***
.35***
.17*
.23**
57.04
14.27
.87
.75***
.38***
.50***
.35***
.29***
.38***
.37***
.52***
.19*
.52***
.43***
20.21
7.69
.87
.37***
.48***
.34***
.42***
.40***
.41***
.56***
.22**
.48***
.57***
24.65
8.22
--a
.68***
.35***
.42***
.36***
.23**
.30***
.24**
.25**
.23**
-.01
.26
--a
.39***
.40***
.60***
.33***
.40***
.17*
.38***
.30***
-.02
.47
.83
.26**
.26**
.68***
.33***
.21*
.29***
.35***
6.12
1.53
--a
.68***
.44***
.48***
.29***
.36***
.29***
.00
.32
--a
.38***
.45***
.18*
.36***
.25**
.01
.60
.87
.38***
.18*
.34***
.35***
5.91
1.58
.92
.57***
.66***
.56***
20.80
8.72
.91
.26**
.75***
57.39
14.67
.84
.25**
18.66
6.88
.89
23.04
7.72
Note. n = 150.
Alphas are presented in bold on the diagonal.
a
Cronbach alphas were not computed because this variable is represented by a single indicator.
T1 = Time 1. M6 = Month 6. Y3 = Year 3. Y4 = Year 4. Self Crit. = Self Critical Perfectionism. Perfectionism. GDD = General Distress
Depressive Symptoms. GDA = General Distress Anxious Symptoms. AD = Anhedonic Depression. AA = Anxious Arousal. SR SAD = StressSadness Reactivity. SR NA = Stress-Negative Affect Reactivity. Agg St. = Aggregated Stress.
* p < .05; ** p < .01; *** p < .001
!
63
Table 2
Bootstrap Analysis of Magnitude and Statistical Significance of Indirect Effects
Indirect Effects
β (Standardized Path
Coefficient and Product)
95% CI for Mean
a
Indirect Effects
(Lower to Upper)
A. T1 Self-Criticism/GDD ! M6 Stress Reactivity ! Y3 Stress Reactivity ! Y4 GDD
A1. T1SC!M6SR!Y3SR!Y4GDD
A2. T1SC!Y3SR!Y4GDD
A3. T1GDD!M6SR!Y3SR!Y4GDD
A4. T1GDD!Y3SR!Y4GDD
A5. M6SR! Y3SR ! Y4GDD
(.303)×(.246)×(.281) = .021
(.186)×(.281) = .052
(.184)×(.246)×(.281) = .013
(.257)×(.281) = .072
(.246)×(.281) = .069
[.040, .414*]
[.016, 1.044*]
[-.002, .033]
[.019, .014*]
[.071, 4.526*]
B. T1 Self-Criticism/AD!M6 Stress Reactivity !Y3 Stress Reactivity ! Y4 AD
B1. T1SC!M6SR!Y3SR !Y4AD
B2. T1SC!Y3SR!Y4AD
B3. T1AD!M6SR!Y3SR!Y4AD
B4. T1AD!Y3SR!Y4AD
B5. M6SR!Y3SR!Y4AD
(.388)×(.275)×(.195) = .021
(.276)×(.195) = .054
(.058)×(.275)×(.195) = .003
(.112)×(.195) = .022
(.275)×(.195) = .054
[.046, .713*]
[.011, 1.747*]
[-.009, .019]
[-.017, .065]
[.050, 6.561*]
C. T1 Self-Criticism/GDA!M6 Stress Reactivity !Y3 Stress Reactivity ! Y4 GDA
C1. T1SC!M6SR!Y3SR !Y4GDA
C2. T1SC!Y3SR!Y4GDA
C3. T1GDA!M6SR!Y3SR!Y4GDA
C4. T1GDA!Y3SR!Y4GDA
C5. M6SR!Y3SR!Y4GDA
(.305)×(.275)×(.226) = .019
(.320)×(.226) = .072
(.233)×(.275)×(.226) = .014
(.029)×(.226) = .006
(.275)×(.226) = .062
[.029, .295*]
[.015, .963*]
[.002, .032*]
[-.025, .038]
[.047, 3.281*]
Note. n = 150.
T1 = Time 1. M6 = Month 6. Y3 = Year 3. Y4 = Year 4.
SC = Self-Criticism. GDD = General Distress Depressive Symptoms. AD = Anhedonic
Depression. GDA = General Distress Anxious Symptoms. SR = Stress-Sadness Reactivity.
a
These values are based on the unstandardized path coefficients.
* p < .05
64
Figure 1. Hypothesized model relating Time 1 self-critical perfectionism, Time 1 general and
specific factors of depressive and anxious distress, Month 6 and Year 3 stress-sadness reactivity,
and Year 4 general and specific factors of depressive and anxious distress.
Time 1 SelfCritical
Perfectionism
Month 6
Stress-Sadness
Reactivity
Time 1
GDD/AD/
GDA/AA
Year 3
Stress-Sadness
Reactivity
Year 4
GDD/AD/
GDA/AA
65
Figure 2. Standardized parameter estimates of the final structural model relating Time 1 selfcritical perfectionism, Time 1 general distress depressive symptoms (GDD), Month 6 and Year 3
stress-sadness reactivity, and Year 4 GDD. The residual arrows denote the proportion of
variance in the measured variable that was unaccounted for by other variables in the model.
Note. * p < .05; ** p < .01; *** p < .001
Time 1 SelfCritical
Perfectionism
.21*
.62***
.66
Time 1
GDD
Time 1 SelfCritical
Perfectionism
Year 4
GDD
.74***
.19*
.30**
Month 6
Stress-Sadness
Reactivity
.62***
.69
.80
.25**
Year 3
Stress-Sadness
Reactivity
.28***
.62
.18*
Time 1
GDD
.26**
.43***
Year 4
GDD
66
Figure 3. Standardized parameter estimates of the final structural model relating Time 1 selfcritical perfectionism, Time 1 anhedonic depressive symptoms (AD), Month 6 and Year 3 stresssadness reactivity, and Year 4 AD. The residual arrows denote the proportion of variance in the
measured variable that was unaccounted for by other variables in the model.
Note. * p < .05; ** p < .01; *** p < .001
Time 1 SelfCritical
Perfectionism
.24**
.52***
.84
Time 1
AD
Time 1 SelfCritical
Perfectionism
Year 4
AD
.23*
.28**
.39***
Month 6
Stress-Sadness
Reactivity
.52***
.72
.82
.28***
Year 3
Stress-Sadness
Reactivity
.20*
.85
.06
Time 1
AD
.11
.28***
Year 4
AD
67
Figure 4. Standardized parameter estimates of the final structural model relating Time 1 selfcritical perfectionism, Time 1 general anxious symptoms (GDA), Month 6 and Year 3 stresssadness reactivity, and Year 4 GDA. The residual arrows denote the proportion of variance in
the measured variable that was unaccounted for by other variables in the model.
Note. * p < .05; ** p < .01; *** p < .001
Time 1 SelfCritical
Perfectionism
.11
.48***
.72
Time 1
GDA
.46***
Time 1 SelfCritical
Perfectionism
.32***
.31***
.73
.78
Month 6
Stress-Sadness
Reactivity
.48***
Year 4
GDA
.28***
Year 3
Stress-Sadness
Reactivity
.23**
.68
.23**
Time 1
GDA
.03
.45***
Year 4
GDA
68
Bridge to Article 2
Article 1 aimed to explain the relationship between self-critical perfectionism and distress
symptoms over time in a sample of community adults. More specifically, Article 1 examined
whether emotional reactivity to daily stress appraisals explained the relationship between SC
perfectionism and depressive and anxious symptoms over a four-year period, controlling for
baseline symptoms. Results demonstrated that stress-sadness reactivity (i.e. daily increases in
sadness in response to daily increases in stress) at Month 6 and Year 3 mediated the relationship
between SC perfectionism and general depressive and anxious symptoms, as well as anhedonic
depressive symptoms over time. Article 1 also examined alternative mediators, including stressnegative affect (NA) reactivity and average levels of daily stress, in the relationship between SC
perfectionism and distress symptoms. Thus, Article 1 addressed whether a specific form of
emotional reactivity (i.e. stress reactivity) explained the relationship between personality
vulnerability and subclinical symptoms over time.
Article 2, which was also based on the same community sample over a period of four
years, aimed to further expand our understanding of the relationship between SC perfectionism
and negative outcomes by examining interpersonal stress generation as a negative outcome.
Article 2 focused on stress generation as a maladaptive outcome in an effort to better understand
what explains the relationship between SC perfectionism and factors that precede the onset of
clinical symptoms. Article 2 included a measure of emotional reactivity that has been shown to
relate to stress generation, namely interpersonal sensitivity (i.e. daily fluctuations in mood in
response to daily increases in negative social interactions). Thus, the goal of Article 2 was to
address whether interpersonal sensitivity helps to explain the relationship between SC
perfectionism and clinical vulnerability factors (i.e. stress generation) over a period of four years.
69
Article 2
Self-Critical Perfectionism, Daily Interpersonal Sensitivity, and Stress Generation:
A Four-Year Longitudinal Study
Tobey Mandel, David M. Dunkley and Claire J. Starrs
Lady Davis Institute–Jewish General Hospital and McGill University
Mandel, T., Dunkley, D. M., & Starrs, C. J., (In preparation). Self-critical perfectionism, daily
interpersonal sensitivity, and stress generation: A four-year longitudinal study.
70
Abstract
Objective: This study of 145 community adults examined heightened interpersonal-sadness
sensitivity as a mediator of the relationship between self-critical (SC) perfectionism and stress
generation four years later. Method: Participants completed questionnaires assessing
perfectionism dimensions at Time 1, baseline depressive symptoms at Time 1 and Year 3, daily
negative social interactions and affect for 14 consecutive days at Month 6 and Year 3, and a
contextual-threat stress interview at Year 4. Results: Path analyses indicated that SC
perfectionism predicted daily interpersonal-sadness sensitivity (i.e., greater increases in sadness
in response to increases in negative social interactions) between Month 6 and Year 3. This, in
turn, explained why individuals with higher SC perfectionism had greater interpersonal stress
generation four years later, controlling for the effects of depressive symptoms. Findings also
demonstrated that responding to negative social interactions with broader negative affect or
accumulated negative social interactions did not mediate the prospective relation between SC
perfectionism and interpersonal stress generation. SC perfectionism was not related to Year 4
noninterpersonal stress generation or independent stress. Conclusion: Findings highlight the
importance of targeting interpersonal-sadness sensitivity in order to reduce the propensity of SC
perfectionistic individuals to generate negative interpersonal life events several years into the
future.
Keywords: self-criticism, perfectionism, interpersonal-sadness sensitivity, stress
generation, contextual-threat stress interview
71
Self-Critical Perfectionism, Daily Interpersonal Sensitivity, and Stress Generation: A FourYear Longitudinal Study
Stress has been implicated in the development and exacerbation of a wide range of
mental health difficulties including anxiety and depression (e.g., Marin et al., 2011), as well as
significant physical health conditions, such as cancer, stroke, and heart disease (e.g., S. Cohen,
Janicki-Deverts, & Miller, 2007). The stress generation perspective posits that individuals play
an active role in constructing their environments through their interactions and choices, such that
they contribute to the occurrence of negative stressful events (Hammen, 1991; Hewitt & Flett,
2002). The stress generation perspective focuses on identifying negative life events that are at
least partially due to the individual’s behavior or characteristics, which are referred to as
dependent events (e.g., an argument with a friend, performance on an exam) (Hammen, 1991;
2006). On the other hand, ‘fateful’ random negative events whose occurrence is unrelated to
personality characteristics are referred to as independent events (Hammen, 2006). Furthermore,
the stress generation perspective emphasizes the importance of assessing dependent interpersonal
stressors as these have been shown to play a more significant role in increasing negative
outcomes over time (Hammen 2005; 2006; Vrshek-Schallhorn et al., 2015). Given the
deleterious impact of stress on well-being, as well as the specific relevance of interpersonal
stressors, research must better identify those factors that contribute to and explain the generation
of future interpersonal negative life events.
Perfectionism is an important multidimensional personality construct that has been
associated with stress generation (Chang, 2000; Hewitt & Flett, 2002; Hammen, 2006). Although
perfectionism has been described using a number of distinct conceptualizations (Blatt, D'Afflitti,
& Quinlan, 1976; Frost, Marten, Lahart, & Rosenblate, 1990; Hewitt & Flett, 1991; Slaney, Rice,
72
Mobley, Trippi, & Ashby, 2001), research has identified two higher-order dimensions of
perfectionism, referred to as personal standards (PS) perfectionism and self-critical (SC)
perfectionism (Dunkley, Zuroff, & Blankstein, 2003; Stoeber & Otto, 2006). PS perfectionism is
defined as having and working towards achieving high standards and goals for oneself. SC
perfectionism, on the other hand, involves harshly critical attitudes towards oneself as well as
concerns regarding others’ approval and possible criticism (Dunkley et al., 2003). SC
perfectionism may be associated with interpersonal stress generation because these individuals
harshly judge themselves and others, direct their attention towards their perceived shortcomings,
and are highly sensitive to negative feedback, all of which contribute to increased conflict and
disruption in interpersonal relationships (Hewitt & Flett, 2002). Research has demonstrated that
SC perfectionism, in contrast to PS, is associated with the presence of stress over both the shortand long-term (Achtziger & Bayer, 2013; Chang, 2000; Dunkley, Mandel, & Ma, 2014; Dunkley
et al., 2003). Empirical findings have demonstrated that facets of SC perfectionism contribute to
the generation of friendship and roommate stress (Shahar, Joiner, Zuroff & Blatt, 2004),
interpersonal negative events over a period of several months (Priel & Shahar, 2000),
interpersonal daily hassles (Hewitt & Flett, 1993), and less trust and self-disclosure in their
romantic relationships (Zuroff, Mongrain, & Santor, 2004).
Although previous research has explored the relationship between SC perfectionism and
stress generation, much of this work has examined stress generation as an explanatory variable
between SC perfectionism and negative outcomes. Researchers have only recently begun to
explore potential mechanisms through which SC perfectionists generate stressors for themselves
(Achtziger & Bayer, 2013). The purpose of the present study was to better understand why
73
individuals with higher SC perfectionism are more likely to generate stress over time (Hammen,
2006).
Self-Critical Perfectionism, Daily Interpersonal Sensitivity, and Stress Generation
One mechanism through which SC perfectionism is theorized to relate to stress
generation is interpersonal sensitivity (Hewitt & Flett, 2002). Interpersonal sensitivity refers to
the degree to which an individual’s mood fluctuates in response to negative social interactions,
such as anger, insensitivity, and/or interference from others (Finch, Okun, Pool, & Ruehlman,
1999; O'Neill, Cohen, Tolpin, & Gunthert, 2004; Parrish, Cohen, & Laurenceau, 2011). These
changes occur within the individual, where highly reactive individuals report larger increases in
negative emotions when appraising social interactions as adverse. Individuals with higher SC
perfectionism are thought to be especially sensitive to interpersonal stressors because they were
raised in controlling and demanding early environments, with harsh and punitive parents whose
approval was conditional on their child meeting and surpassing unrealistic expectations (Blatt,
1995). As a result, SC perfectionists are constantly preoccupied with gaining approval and
admiration, and chronically fear being criticized by important others (see Blatt, 1995; Dunkley,
Berg, & Zuroff, 2012). They may, therefore, be particularly sensitive to negative social
exchanges as these are experienced as a form of personal failure, which may in turn contribute to
feelings of loss of belonging and acceptance (Besser & Priel, 2005).
Empirical findings have demonstrated that SC perfectionistic individuals demonstrate
increased sensitivity to interpersonal difficulties. In prior analyses based on the same sample,
Dunkley, Mandel, et al. (2014) used daily diaries to assess the prospective impact of SC
perfectionism on the within-person relationship between negative social interactions and both
sadness and negative affect at two future time points. Results from multilevel modeling of cross-
74
level interactions showed that high SC perfectionists had heightened increases specifically in
sadness, but not broader negative affect, on days where they experienced more negative social
interactions than usual, both six months and three years after their initial measures. Similarly, SC
perfectionistic individuals have been found to be emotionally reactive to both perceived
criticism, as well as fears of closeness (Dunkley, Berg, et al., 2012; Dunkley et al., 2003). Core
dislike of the self, one aspect of self-criticism, has been correlated with negative affective
responses to interpersonal stress (Joo, Yeon, & Lee, 2012). Furthermore, individuals with higher
SC perfectionism have also been shown to experience neutral interpersonal interactions as
negative and threatening (Hewitt & Flett, 2002).
Heightened interpersonal sensitivity may explain the link between higher SC
perfectionism and stress generation because the tendency to overreact to negative interpersonal
interactions with intensified feelings of sadness and dejection may transform the experience of
benign situations into stressful ones (see Hewitt & Flett, 2002; Zuroff, Mongrain, & Santor,
2004). This heightened reactivity may lead an individual to exhibit excessive reassurance
seeking and to overreact to even mild slights (Hewitt & Flett, 2002). More specifically, constant
reassurance seeking and overacting to minor comments may lead others to withdraw, escalating
reassurance needs, and precipitating a spiral of negative interpersonal stressors that are
dependent upon the individual (Starr & Davila, 2008).
Although prior research has established links between SC perfectionism, interpersonal
sensitivity, and stress generation, there remain four important gaps in the literature that require
attention. First, to our knowledge, no research to date has specifically examined whether
interpersonal sensitivity explains why SC perfectionistic individuals have heightened
vulnerability to experiencing stress generation. Interpersonal sensitivity as a mediator variable
75
extends beyond the simple measurement of either negative social interactions or mood variables
alone; rather it represents the relationship between negative social interactions and mood over
time within each individual. This innovative method of analysis uses daily diaries to gather a
sequence of data points, and then uses multilevel modeling to derive the within-person
relationship between negative social interactions and mood, represented by a slope, for each
participant. These interpersonal sensitivity slopes can then be used as independent or mediator
variables to examine increasingly complex hypotheses (L. H. Cohen, Gunthert, Butler, O'Neill,
& Tolpin, 2005; Cole et al., 2014). This method of analysis has been used in two previous
studies (O'Neill et al., 2004; Parrish et al., 2011) that both found that undergraduates who were
more reactive to daily interpersonal stressors were more likely to have increases in depressive
symptoms two months later. Although prior research has demonstrated the harmful nature of
daily interpersonal sensitivity, further research is needed in order to examine whether
interpersonal sensitivity predicts stress generation outcomes and whether it can explain the
relationship between SC perfectionism and prospective stress generation.
Second, although personality is generally considered relatively stable (McCrae & Costa,
2008), the stability of interpersonal sensitivity has yet to be examined. Dunkley, Mandel, et al.
(2014) showed that SC perfectionists were emotionally reactive to negative social interactions at
both Month 6 and Year 3. However, these analyses did not evaluate the stability of interpersonal
sensitivity as they were done separately at each time point. Emotional reactivity patterns
constitute an important component of an individual’s vulnerability, as they represent emotional
lability, specifically in response to interpersonal stressors (Singer, 2013; Sliwinski, Almeida,
Smyth, & Stawski, 2009).
76
Third, Dunkley, Mandel, et al. (2014) demonstrated that SC perfectionists responded to
higher levels of negative social interactions with greater increases in sadness but not more broad
negative affect. This distinction may be important because research has shown that sadness
encompasses more disengagement-like emotions such as feeling lonely, blue, and despondent,
whereas negative affect incorporates more active emotions such as anger and frustration
(Watson, Clark, & Stasik, 2011). Sadness may elicit more avoidance and withdrawal behaviors
that serve to increase the severity, duration, or both, of daily interpersonal conflicts, thereby
contributing to major interpersonal negative events in the future (e.g., loss of relationships). On
the other hand, active negative emotions (e.g., anger) may facilitate more protective ‘approach’
behaviors that encourage the individual to actively engage or cope with the presenting conflict
(see Carver & Harmon-Jones, 2009; Lindebaum & Jordan, 2014). Research has yet to establish,
however, whether reacting to negative social interactions with sadness (referred to as
interpersonal-sadness sensitivity) as compared to negative affect (referred to as interpersonal-NA
sensitivity) better explains the relation between SC perfectionism and future interpersonal stress
generation.
Finally, previous research has demonstrated that negative social exchanges are related to
major stressful life events (Lakey, Tardiff, & Drew, 1994; Edwards, Hershberger, Russell, &
Markert, 2001). However, research has yet to examine whether an individual’s emotional
response to negative social interactions predicts stress outcomes several years later. Theorists
have suggested that reactions to an event may be a greater predictor of maladjustment than the
event itself (Beck, Rush, Shaw, & Emery, 1979). Appraisals of negative social interactions are
distinct from interpersonal-sadness sensitivity, as the former refers to individual differences in
levels of negative social interactions, whereas the latter refers to individual differences in the
77
strength of the relationship between appraisals of daily negative social interactions and mood
(Tong, 2010). Research is needed in order to evaluate whether it is an individual’s average levels
of negative social interactions or the strength of the emotional response to them that best
explains the relationship between SC perfectionism and future stress outcomes.
The Present Study Aims and Hypotheses
The present study was the first to examine daily interpersonal-sadness sensitivity as an
explanatory variable in the relationship between SC perfectionism and stress generation several
years later. In order to examine this, interpersonal sensitivity slopes were created representing an
individual’s relationship between negative social exchanges and sadness at both Month 6 and
Year 3. These slopes were then used as sequential mediators in the relationship between SC
perfectionism and stress generation four years later. Additionally, we examined interpersonalNA sensitivity as a potential alternative mediator in the relation between SC perfectionism and
stress generation in order to examine the relevance of responding to interpersonal stress
specifically with sadness versus broader negative affect. Finally, we also assessed whether
average levels of negative social interactions, as opposed to interpersonal-sadness sensitivity,
better explained the relation between SC perfectionism and later stress generation.
A major methodological strength of the current study involved using a contextual-threat
interview (Hammen, 1991) to assess interpersonal stress generation. The majority of prior
research has relied on self-report stress checklists to assess negative life events as opposed to
performing contextual-threat interviews, which rely on objective team-ratings of events (Luyten
et al., 2011). Research has shown that interviews control for the influence of participants’ current
mood and subjective biases due to personality characteristics, as well as inflated reporting of
minor events (McQuaid, Monroe, Roberts, Kupfer, & Frank, 2000; Ostiguy et al., 2009).
78
Previous research has demonstrated that facets of SC perfectionism are related to not only
interpersonal stress but also noninterpersonal stress generation (Priel & Shahar, 2000; Shih,
Abela, & Starrs, 2009). As a result, the current study examined both interpersonal and
noninterpersonal stress generation outcomes separately in order to verify whether interpersonalsadness sensitivity leads SC perfectionists to specifically generate more interpersonal stressors
(Hammen, 1991). Furthermore, some studies have found SC perfectionism components to be
specifically related to dependent, but not independent, negative events (Shih, Abela, & Starrs,
2009), whereas other studies have shown that SC perfectionism facets are related to both
dependent and independent events (Luyten et al., 2011). Thus, events were further separated into
dependent and independent categories in order to help clarify whether individuals with higher SC
perfectionism are indeed generating negative life events.
Hypotheses
As depicted in Figure 1, based on the above theory and previous empirical findings, we
hypothesized that Time 1 SC perfectionism would uniquely predict Month 6 and Year 3
interpersonal-sadness sensitivity, Month 6 interpersonal-sadness sensitivity would predict Year 3
interpersonal-sadness sensitivity, and Year 3 interpersonal-sadness sensitivity would predict
Year 4 interpersonal stress generation. Given that interpersonal-sadness sensitivity is a dynamic
variable that is somewhat less stable than personality traits, we expected that interpersonalsadness sensitivity would remain moderately stable between Month 6 and Year 3 (see Sliwinski
et al., 2009). Most importantly, we hypothesized that enduring interpersonal-sadness sensitivity
would mediate the prospective relation between Time 1 SC perfectionism and dependent
interpersonal stressful events four years later. Further, as the potential confounding of
perfectionism with concurrent depressive symptoms is an important issue (see Zuroff et al.,
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2004) and depressive symptoms have been shown to be a predictor of stress generation
(Hammen, 1991), Time 1 and Year 3 depressive symptoms were included in the model as
covariates. We expected that the hypothesized relations would remain significant after
controlling for the effects of depressive symptoms. In addition, we hypothesized that
interpersonal-NA sensitivity and aggregated negative social interactions would provide weaker
explanatory value than interpersonal-sadness sensitivity in explaining the relationship between
Time 1 SC perfectionism and Year 4 dependent interpersonal stress. Finally, we examined
whether the hypothesized mediation model extended to dependent noninterpersonal stress and/or
to independent stress. We expected that the hypothesized model would be specific to
interpersonal stress generation.
Method
Participants
The sample consisted of 145 English- and French-speaking community adults, who were
a subset of an originally larger sample of 223 participants (see Dunkley & Kyparissis, 2008).
Recruitment was done through newspaper advertisements and posted bulletins. Participants were
between the ages of 18-65 and currently employed at the beginning of the study. The study
included questionnaires at Time 1, 14 daily diaries at Month 6 and Year 3, and a contextualthreat stress interview at Year 4. Participants were compensated $25 for completing the Time 1
questionnaires, $75 for each of the Month 6 and Year 3 diaries, and $50 for the Year 4 episodic
stress interview. Participants who did not complete all 14 daily dairies at Month 6 and Year 3
were compensated in proportion to the number of diaries that they had completed.
In order for a participant’s data to be included in the present study, the participant had to
have completed all four time points and at least seven out of 14 daily diaries at the Month 6 and
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Year 3 time points. The final sample consisted of 145 participants (100 women, 45 men) who
completed their Month 6 diaries approximately six months (M = 5.93, SD =.35) after their initial
Time 1 questionnaires, where 142 participants completed all 14 days of daily diaries, one
participant completed 13 consecutive diaries, one participant completed 13 days of daily diaries
with one day of item nonresponse (i.e. Day 12 is missing), and one participant completed 12
daily diaries with two days of item nonresponse. Participants completed their second set of
diaries approximately three years after Time 1 (M = 36.70 months, SD = .91), with 139
participants completing all 14 daily diaries, one participant completing 13 consecutive diaries,
two participants completing 13 days of diaries with one day of item nonresponse, one participant
completing 12 consecutive diaries, one participant completing 10 consecutive diaries, and one
participant completing eight consecutive diaries. The sample had a mean age of 41.2 years (SD =
12.28), and participants were primarily of European descent (76%), with 7% Asian, 3% East
Indian, 3% Middle Eastern, 2% African, 1.5% South American, 1.5% Aboriginal, 1% Caribbean,
and 5% unspecified. Participants either completed the English version of the questionnaires (57
female, 24 male) or the French version of the questionnaires (43 female, 21 male), depending on
their preference.
Procedure
At Time 1, participants were invited to the laboratory for a 1.5 to 2-hour session in order
to complete questionnaires assessing demographic information, personality, and depressive
symptoms. Participants were then invited back to the lab six months and again three years later
to collect 14 stamped and addressed envelopes, each containing a daily diary questionnaire
booklet. The daily diary packages contained questionnaires measuring daily affect and negative
social interactions. Each section of the daily diary was explained in detail, and participants were
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asked to complete one daily diary at bedtime, beginning that evening, consecutively for the next
14 nights. Participants were then asked to mail the completed daily diary booklet the following
morning. Participants were urged to complete their diary each evening; however, if this was not
feasible, they were asked to complete them as soon as possible the following morning. At Year
3, participants were also asked to complete questionnaires assessing their current depressive
symptoms. At Year 4, participants were invited back to the lab for a 60-75 minute interview,
where they were asked about stressful life events that had occurred throughout the last year.
Measures
Questionnaires and daily diary booklets were available in both English and French, as the
given sample consisted of both English and French speaking participants. The French versions of
the Time 1 perfectionism and depressive symptoms measures (see Dunkley, Blankstein, & Berg,
2012; Dunkley & Kyparissis, 2008) and the Month 6 and Year 3 daily negative social
interactions and affect measures (see Dunkley, Ma, Lee, Preacher, & Zuroff, 2014; Dunkley,
Mandel, et al., 2014) were found to have similar internal consistencies and validity as the English
equivalents.
Perfectionism. The SC and PS perfectionism measures were created from the 45-item
(Hewitt & Flett, 1991) Multidimensional Perfectionism Scale (HMPS), the 35-item (Frost et al.,
1990) Multidimensional Perfectionism Scale (FMPS), the 23-item Almost Perfect Scale-Revised
(APS-R; Slaney et al., 2001), the 66-item Depressive Experiences Questionnaire (DEQ; Blatt et
al., 1976), and the 40-item Dysfunctional Attitude Scale (DAS; Weissman & Beck, 1978). Based
on findings from previous factor analyses (Dunkley, Ma, et al., 2014; Powers, Zuroff, & Topciu,
2004; see Stoeber & Otto, 2006 for a review), SC was indicated by DEQ self-criticism, DAS
self-criticism, FMPS concern over mistakes, HMPS socially prescribed perfectionism, and APS-
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R Discrepancy. PS was assessed by HMPS self-oriented perfectionism, FMPS personal
standards, and APS-R high standards. The reliability and validity of the DEQ (e.g., Zuroff et al.,
2004), DAS (e.g., Dunkley & Kyparissis, 2008; Powers et al., 2004), APS-R (e.g., Slaney et al.,
2001), HMPS (e.g. Hewitt & Flett, 1991), and FMPS (e.g., Frost et al., 1990) have been wellestablished. Coefficient alphas for DEQ self-criticism (coefficient alpha for a weighted
composite), DAS self-criticism, FMPS concern over mistakes, HMPS socially prescribed
perfectionism, APS-R discrepancy, FMPS personal standards, HMPS self-oriented
perfectionism, and APS-R high standards were .81, .90, .88, .89, .95, .81, .90, and .88,
respectively. As was done in previous research (Dunkley, Berg, et al., 2012; Dunkley, Mandel, et
al., 2014; Dunkley et al., 2003), the DEQ, DAS, FMPS, HMPS, and APS-R measures were
standardized and saved as z-scores, and then averaged together to create the relevant SC and PS
perfectionism composite scores. The validity of these higher-order dimensions has been
established in previous studies (e.g., Dunkley, Mandel, et al., 2014; Dunkley et al., 2003; see
Stoeber & Otto, 2006). Cronbach’s alphas for the SC perfectionism and PS perfectionism
composite scores in the present study were .79 and .79, respectively.
Depressive Symptoms. Depressive symptoms were evaluated using the Beck Depression
Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a 21-item self-report
questionnaire measuring current depression levels. Participants rated how they were feeling over
the past week, with higher scores indicating more severe levels of depression. The internal
consistency and validity of the BDI has been well-established (Beck, Steer, & Carbin, 1988). In
the present study, the Cronbach’s alpha for the BDI was .86.
Daily Affect. Five adjectives from the Positive and Negative Affect Schedule-Expanded
(PANAS-X; Watson & Clark, 1994) were administered in order to assess sadness for today.
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Negative affect for today was measured using the 10-item negative affect scale of the PANAS
(Watson, Clark, & Tellegen, 1988). The daily sadness and negative affect measures have been
found to be reliable and valid (e.g., Dunkley, Mandel, et al., 2014). The within- and betweenperson reliabilities were computed using Cranford and colleagues’ (2006) procedure, and were
.81 and .79 at Month 6, and .79 and .85 at Year 3 for sadness, and were .80 and .80 at Month 6,
and .79 and .84 at Year 3 for negative affect, respectively.
Negative Social Interactions. The revised 24-item Test of Negative Social Exchange
(TENSE; Finch et al., 1999) was used to measure negative social interactions. Participants rated
how often they experienced various types of negative social interactions (e.g., anger,
insensitivity, interference) today. Reliability and validity for the TENSE has been wellestablished (e.g., Dunkley, Mandel, et al., 2014; Finch et al., 1999). Computed using Cranford
and colleagues’ (2006) procedure, the within- and between-persons reliabilities in the present
study were .94 and .93 at Month 6, and .95 and .94 at Year 3, respectively.
Contextual-Threat Stress Interview. The UCLA Life Stress Interview (Hammen, 1991)
is a semi-structured contextual-threat interview that assesses episodic negative events. Events
were elicited by asking participants if they had experienced any discrete life events during the
last 12 months. If participants had difficulty recalling events, they were shown a list of possible
life events in order to facilitate recollection. For participants who completed the study in French,
bilingual graduate students translated general probes from English to French using forward and
backward translation techniques in order to ensure that the meaning of each probe was retained.
Participants described each event in detail, and the interviewer documented the facts without
including the subjective emotional reactions of the participant.
The interviewer then presented the information to a team of independent raters, who
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coded each event in terms of its degree of contextual threat, whether the event was interpersonal
or noninterpersonal, as well as dependent or independent of the individual. An event was deemed
to be a negative interpersonal event if it involved: interpersonal loss, social rejection, disapproval
from significant others, disruption in relationships, or abandonment. All other events were
considered noninterpersonal. Contextual threat was determined by rating the event’s objective
impact on an average person in an identical context using a 5-point scale ranging from 1 (no or
minimal impact) to 5 (severe impact) with increments of 0.5 (Hammen, 1991; Uliaszek et al.,
2012). Positive events were not retained. Dependence ratings represented the degree to which the
occurrence of the event was dependent upon the individual’s behavior using a 5-point scale
ranging from 1 (entirely independent of the person) to 5 (entirely dependent on the person), with
a score of 3 or higher being considered a dependent event (Hammen, 1991; Ostiguy et al., 2009).
Events were then separated into four distinct categories: dependent interpersonal, dependent
noninterpersonal, independent interpersonal, and independent noninterpersonal events. Objective
impact severity scores were calculated by summing the objective contextual-threat ratings across
all events in each category (Ostiguy et al., 2009). Inter-rater reliability was established by having
two separate groups of doctoral level graduate students in clinical psychology and licensed
clinical psychologists with doctoral degrees rate the interpersonal nature, objective severity and
independence of 60 events. The single measure intraclass correlation coefficients (ICC) for the
interpersonal nature, objective severity and independence portions of the interview were .91, .90
and .91, respectively, which is in line with what has been reported in previous studies (Hammen,
1991; Hammen & Brennan, 2002). Having established reliability, one of the teams coded the
remainder of the events.
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Model Testing
We created daily interpersonal sensitivity variables by conducting multilevel modeling
using SAS PROC MIXED (Version 9.2) and maximum likelihood estimation. More precisely,
within-person daily variability in sadness and negative affect was predicted from within-person
daily fluctuations in negative social interactions (with the slope modeled as randomly varying
across participants). The individual slopes were empirical Bayes estimates, and the variance
associated with these slopes was significant. The resulting regression coefficient represents a
personal slope for each participant representing their degree of reactivity in response to negative
interpersonal interactions. This individualized slope was then used as a between-persons
interpersonal sensitivity variable in all subsequent path analyses.
Path model testing was performed using Analysis of Momentary Structure 5.0 (AMOS
Version 5.0; Arbuckle, 2003) in order to test for the mediated effects of Time 1 SC perfectionism
on Year 4 dependent interpersonal stress through Month 6 and Year 3 interpersonal sensitivity,
controlling for Time 1 and Year 3 depressive symptoms. Consistent with recommendations from
Hoyle & Panter (1995), we considered incremental fit index (IFI) and comparative fit index
(CFI) values above .95 and Root Mean Square Error of Approximation (RMSEA) values below
.06 (Browne & Cudeck, 1993) as indicating acceptable model fit (see Hu & Bentler, 1999). In
order to evaluate whether the relations between SC perfectionism and Year 4 dependent
interpersonal stress was fully or partially mediated by interpersonal sensitivity, we performed
nested comparisons between the hypothesized fully mediated model (see Figure 1) and a
partially mediated model that included a direct path between Time 1 SC perfectionism and Year
4 dependent interpersonal stress. As suggested by Hoyle and Panter (1995), we compared the
models using a chi-square difference test and fit indices that take into account model complexity.
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The parsimony-adjusted indices of fit that were used to compare the models were the Akaike
information criterion (AIC) and the Bayes information criterion (BIC), where smaller values are
preferred and the BIC more strongly favors more parsimonious models (see Arbuckle, 2003). If
the contrasting models demonstrated no significant difference, the more parsimonious, fully
mediated model was retained (see Klein, 2005). Finally, indirect effects were tested using the
Monte Carlo bootstrap procedure in AMOS (Arbuckle, 2003), where 2,000 bootstrap samples
were created by randomly sampling and replacing the original data. These tests were based on
95% bias-corrected confidence intervals (CI), where any CI that did not include zero was
considered statistically significant at p < .05.
Results
Descriptive Statistics
The Time 1 SC and PS perfectionism and BDI measures had item nonresponse
percentages ranging between 0% for the FMPS concern over mistakes items and 1.3% for the
BDI items. At Month 6, 145 participants completed a total of 2,026 out of a possible 2,030 daily
measures of negative social interactions and sadness, where a single report was considered
missing due to attrition and three reports were missing due to item nonresponse. At Year 3,
participants completed a total of 2,015 reports out of a possible 2,030 reports, where 13 were
found to be missing due to attrition and two were considered missing due to item nonresponse.
Item nonresponse percentages were calculated for both the Month 6 and Year 3 diaries and
ranged between 0% for the Month 6 sadness items and 1.2% for Year 3 negative social
interactions. Percentages for missing variables at both time points were below 0.01%. Missing
data for the interpersonal sensitivity variables were dealt with using a maximum likelihood
method in SAS Version 9.2 (see Schlomer, Bauman, & Card, 2010).
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The total number of episodic events reported was 378, where participants reported
between zero and seven events (M = 2.61, SD =1.29). Of these, the number of dependent
interpersonal events was 119, the number of dependent noninterpersonal events was 84, the
number of independent interpersonal events was 56, and the number of independent
noninterpersonal events was 119. The means and standard deviations for the Time 1
perfectionism and depression measures, Month 6 and Year 3 interpersonal-sadness and
interpersonal-NA sensitivity and aggregated negative social interactions variables, and Year 4
episodic stress scores are shown in Table 1. The means of the Time 1 perfectionism and
depression measures (Dunkley, Blankstein, et al., 2012; Dunkley & Kyparissis, 2008), and the
Month 6 and Year 3 negative social interactions and affect measures (Dunkley, Ma, et al., 2014;
Dunkley, Mandel et al., 2014) were found to be comparable between individuals who completed
English and French questionnaires. No significant differences were found when we ran
independent sample T tests in order to compare English and French episodic stress scores. In
addition, given that the present sample was a subset of an original sample of 223 participants
recruited for a larger community study, T tests were performed comparing the means of the Time
1 perfectionism and depressive symptoms measures. Results from the T tests revealed that there
were no significant differences between the current study’s subsample of 145 participants and
the additional 78 participants from the original sample.
Zero-order Correlations
Zero-order correlations are reported in Table 1 between Time 1 SC perfectionism and PS
perfectionism, Time 1 and Year 3 depressive symptoms, Month 6 and Year 3 daily interpersonalsadness and -NA sensitivity and aggregated negative social interactions, and Year 4 episodic
stress outcomes. Time 1 SC perfectionism exhibited stronger correlations than PS perfectionism
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with Month 6 and Year 3 interpersonal-sadness sensitivity and Year 4 dependent interpersonal
stress. None of the Time 1, Month 6, or Year 3 variables correlated with the other Year 4 stress
outcomes (dependent noninterpersonal stress and independent stress). In contrast to
interpersonal-NA sensitivity and aggregated negative social interactions, Month 6 and Year 3
interpersonal-sadness sensitivity correlated with Year 4 dependent interpersonal stress.
Path Analyses relating SC Perfectionism, Interpersonal-Sadness Sensitivity, and
Dependent Interpersonal Stress
As shown in Figure 1, our model included six measured variables: Time 1 SC
perfectionism, Month 6 and Year 3 interpersonal-sadness sensitivity, and Year 4 dependent
interpersonal stress, with Time 1 and Year 3 depressive symptoms included as covariates. Our
hypothesized path model was tested with the inclusion of PS perfectionism. PS perfectionism did
not provide unique explanatory value and, therefore, was not retained as a predictor in the
following analyses, consistent with previous studies (Dunkley et al., 2003; Mandel, Dunkley, &
Moroz, 2015). Further, given that none of the other stress outcomes were correlated with any of
the predictors or mediators, these variables were not examined in further analyses.
The hypothesized structural model (see Figure 1) was estimated and had the following
acceptable fit indices: χ2 (3, N=145) = 2.73, ns; IFI = 1.00, CFI = 1.00; RMSEA = .00; AIC =
38.73; and BIC = 92.31. Following this, a path was estimated between Time 1 SC perfectionism
and Year 4 dependent interpersonal events in order to contrast a partially mediated model with
the hypothesized fully mediated model. The chi-square difference test was non-significant, Δχ2
(1, N = 145) = 2.46, ns, the BIC was 94.83 for the partially mediated model, and there was
minimal difference in the AIC between models (38.27 for the partially mediated model). Taken
together, the values favored the more parsimonious, fully mediated model. In addition, the direct
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path relating Time 1 SC perfectionism to Year 4 episodic stress (
= .15, p = .12) was
nonsignificant. Thus, the hypothesized mediated model was retained.
As seen in Figure 2, the 95% CI (.063, .610) between Time 1 SC perfectionism and Year
4 dependent interpersonal events supported the conclusion that the effect of SC perfectionism on
interpersonal stress generation was fully mediated by Month 6 and Year 3 interpersonal-sadness
sensitivity, adjusting for the effects of Time 1 and Year 3 depressive symptoms. In addition, SC
perfectionism had a direct effect on Year 3 depressive symptoms, controlling for Time 1
depressive symptoms. Time 1 and Year 3 depressive symptoms were not uniquely related to
interpersonal-sadness sensitivity or interpersonal stress generation in the model.
Supplementary Analyses
Supplementary analyses examined interpersonal-NA sensitivity as a potential explanatory
variable in the relationship between SC perfectionism and Year 4 interpersonal stress generation.
A separate path analysis and tests of indirect effects were conducted examining interpersonal-NA
sensitivity, instead of interpersonal-sadness sensitivity, in the model relating Time 1 SC
perfectionism to Year 4 dependent interpersonal events (see Figure 1). In contrast to the
interpersonal-sadness sensitivity mediation effects, SC perfectionism was not indirectly related
to Year 4 dependent interpersonal events through interpersonal-NA sensitivity. In addition, a
separate path analysis was conducted testing aggregated negative social interactions. In contrast
to the results for interpersonal-sadness sensitivity, SC perfectionism was not indirectly related to
Year 4 dependent interpersonal events through aggregated negative social interactions.
Discussion
The present study is the first to identify interpersonal-sadness sensitivity as an
explanatory variable in the relationship between SC perfectionism and interpersonal stress
90
generation over a period of four years. This research used repeated sequences of daily dairies to
develop individual interpersonal-sadness sensitivity slopes, which were then tested as mediators
in the relationship between SC perfectionism and stress generation four years later. Further, the
present study used a contextual-threat interview to assess the dependence and interpersonal
nature of stressful events, which provided a more stringent examination of the relationship
between SC perfectionism and stress generation.
SC Perfectionism and Interpersonal Stress Generation Four Years Later
The present findings address important gaps in the literature by identifying who is most at
risk for, and which factors contribute to interpersonal stress generation several years into the
future (Hammen, 2006). Our results underscore the impact of SC perfectionism on stress
generation by demonstrating that SC perfectionism was directly related to dependent
interpersonal events four years later. Our findings also show that SC perfectionism was not
related to noninterpersonal stress generation or independent events over time. These results are
consistent with previous research supporting a link between SC perfectionism facets and
interpersonal stress generation (Priel & Shahar, 2000, Shahar et al, 2004; Shih, et al., 2009,
Starrs et al., 2015) and interpersonal daily hassles (Hewitt & Flett, 1993; Dunkley et al., 2003),
but are in contrast to research noting a link between SC perfectionism facets and
noninterpersonal stress generation (Hewitt & Flett, 1993; Priel & Shahar, 2000; Shahar et al.,
2004; Shih et al, 2009). By providing more detailed information regarding which types of stress
individuals with higher SC perfectionism generate over time, our results add to the literature on
the perfectionism stress generation perspective (Hewitt & Flett, 2002). One possible explanation
for the specificity of our findings may be our use of a contextual-threat interview that evaluated
the objective impact, the interpersonal nature, and the degree of dependence of the stressful life
91
events, which is in contrast to most previous research that has relied on subjective self-reports
(Luyten et al., 2011; Priel & Shahar, 2000). Furthermore, in contrast to previous research, the
current study spanned four years, a significantly longer time period, demonstrating that these
relationships extend well into the future, highlighting the particularly detrimental impact of
higher SC perfectionism on stress generation.
SC Perfectionism, Enduring Interpersonal Sensitivity, and Interpersonal Stress Generation
Four Years Later
The present study examined the mediating role of enduring interpersonal-sadness
sensitivity in the prospective relation between SC perfectionism and interpersonal stress
generation four years later. In order to assess for interpersonal-sadness sensitivity, multiple
sequences of daily diaries and multilevel modeling were employed at both Month 6 and Year 3
to create individualized slopes that represent the degree to which an individual’s sadness
fluctuates in response to their daily negative social interactions. This method provided a unique
within-person interpersonal-sadness sensitivity slope, which was then used as an explanatory
mediator in the relationship between SC perfectionism and dependent interpersonal stress four
years later. Previous research testing within-person variables has focused on observing how a
single variable (i.e., mood) fluctuates within an individual (Cole et al., 2014), whereas the
current innovative method assesses how two variables (i.e., negative social interactions and
sadness) fluctuate concurrently within an individual over time.
Our findings demonstrate the enduring nature of interpersonal-sadness sensitivity,
whereby SC perfectionism was indirectly related to Year 3 interpersonal-sadness sensitivity
through Month 6 interpersonal-sadness sensitivity. These findings are in keeping with theory
suggesting that SC perfectionistic individuals are highly sensitive to interpersonal difficulties
92
(Dunkley et al., 2003; Hewitt & Flett, 1993). This hypersensitivity is thought to be due to a harsh
and controlling upbringing, that relied on conditional parental approval, leading them to overly
value the approval of significant others and respond with increased sadness in the face of
negative interpersonal exchanges in adulthood (see Blatt, 1995; Dunkley, Berg, et al., 2012).
The present results extend the perfectionism diathesis-stress model (Dunkley, Mandel, et
al., 2014) by demonstrating that the enduring, heightened interpersonal-sadness sensitivity of
individuals with higher SC perfectionism leads to higher levels of self-generated interpersonal
events in the long-term future. Furthermore, these findings remained significant after controlling
for Time 1 and Year 3 depressive symptoms, suggesting that the effects do not merely represent
concomitants of depressive symptoms (Coyne & Whiffen, 1995). One possible explanation for
these findings is that because individuals with higher SC perfectionism tend to interpret negative
social exchanges as a form of failure and respond with feelings of sadness and dejection (Besser
& Priel, 2005), they tend to respond by avoiding and withdrawing socially from the interaction in
an effort to escape further criticism for the failure (Hewitt & Flett, 2002), which leads to
increased dependent interpersonal negative events in the long-term.
Our findings extend previous research in a number of ways. First, our findings further
recent research aiming to explain the relationship between SC perfectionism facets and higher
levels of perceived stress (Achtziger & Bayer, 2013) by focusing on a more stringent objective
stress measure that includes information on both the dependent and interpersonal nature of each
event, and by examining these relations over a significantly longer period of time. Furthermore,
our results also build on previous research demonstrating the destructive nature of interpersonal
sensitivity in relation to depressive symptoms (O'Neill et al., 2004) by demonstrating
interpersonal sensitivity in relation to other negative outcomes (i.e. interpersonal stress
93
generation) and by identifying it as an important mediator in the relationship between SC
perfectionism and stress generation. Lastly, the present findings advance previous research that
has demonstrated a link between SC perfectionism and stress generation (Shahar, Joiner, et al.,
2004), as well as research that has hypothesized links between self-criticism, disturbed
relationships, and stress generation (Hewitt & Flett, 2002; Zuroff et al., 2004, Starrs et al, 2015)
by identifying interpersonal-sadness sensitivity as a specific mediator explaining the relationship
between SC perfectionism and future interpersonal stress generation.
Interpersonal-NA Sensitivity and Aggregated Daily Negative Social Interactions as
Alternative Mediators
The present study distinguished interpersonal-sadness sensitivity from interpersonal-NA
sensitivity in that interpersonal-NA sensitivity did not mediate the relation between SC
perfectionism and dependent interpersonal stress four years later. These results highlight the
long-term cost of responding to negative social interactions with sadness, as opposed to other
broader negative emotions, as reacting with sadness may elicit more withdrawal and avoidance,
leading to stressful interpersonal life events in the long-term future (see Carver & Harmon-Jones,
2009). To elaborate, the more an individual withdraws and avoids conflict, the less likely they
are to adequately cope with the presenting conflict. As a result, the conflict may become
increasingly problematic, which appears to contribute to stress generation over time.
The present study also distinguished daily interpersonal-sadness reactivity from
aggregated daily negative social interactions. In contrast to interpersonal-sadness reactivity,
average negative social interactions did not mediate the relation between SC perfectionism and
stress generation outcomes four years later. Thus, our findings suggest that individuals with
higher SC perfectionism do not experience stress generation because they are exposed to
94
negative social interactions, but rather because they respond to negative social interactions with
sadness. This supports the theoretical perspective that it is how one responds to stress, as
opposed to the presence of stress, that better predicts future distress outcomes (Beck et al., 1979).
Clinical Implications
By assessing stress generation outcomes, as opposed to clinical symptoms, our findings
provide important information about how to intervene before the onset of clinically significant
outcomes. In order to prevent escalating stress generation, our results suggest that SC
perfectionistic individuals may benefit from interventions that target daily interpersonal
sensitivity. Our findings indicate that interventions for individuals with higher SC perfectionism
should focus primarily on better regulating the degree of sadness that they experience when they
are exposed to negative social interactions more so than reducing their frequency of negative
social interactions. Emotion regulation skills utilized in dialectical behavioral therapy (DBT;
Linehan, 1993), which aim to lessen the intensity of negative moods by identifying and
describing emotions and by working to respond more effectively to interpersonal stressors, may
be helpful in decreasing sadness. Furthermore, recent interventions have been developed that
utilize cognitive behavioral techniques to specifically target interpersonal sensitivity cognitions
(Bell & Freeman, 2014), which may be helpful for individuals with higher SC perfectionism. In
addition, Interpersonal Therapy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984)
focuses on better coping with present interpersonal dysfunction, as opposed to enduring
personality features, and has been shown to be effective in altering how individuals respond to
and engage with interpersonal difficulties (de Mello, de Jesus Mari, Bacaltchuk, Verdeli, &
Neugebauer, 2005).
95
Limitations and Directions for Future Research
The current study had several notable strengths, including the four-year longitudinal
design, the daily diary methodology, and the contextual-threat interview. However, certain
limitations were present in our methodology and future research should aim to address some of
these shortcomings. First, the predictor, mediator, and outcome variables were not evaluated at
each time point, which would have allowed for stronger causal statements (see Cole & Maxwell,
2003). Future studies should incorporate measures of stress generation at multiple time points in
order to better establish the temporal ordering of these processes (see Uliaszek et al., 2012).
Second, both theory and research suggest that SC perfectionism is related to avoidant coping
(Dunkley, Mandel, et al., 2014), and avoidant coping has been theorized as a potential link
between stress-sadness reactivity and stress generation (see Carver & Harmon-Jones, 2009;
Lindebaum & Jordan, 2014). Therefore, future research should investigate whether avoidance
and withdrawal coping styles do indeed help to explain the relationship between stress-sadness
sensitivity and stress generation for individuals with higher SC perfectionism. Third, in order to
establish whether these implications pertain to other populations, future research should assess
the generalizability of our findings in clinical and other nonclinical populations, including
adolescents and more culturally diverse samples. Lastly, future studies should evaluate the
potential effectiveness of interventions targeting sadness-sensitivity to negative interpersonal
exchanges in order to test whether these interventions help to reduce the development of future
stress generation for SC perfectionistic individuals.
Conclusion
The current study incorporated repeated sequences of daily diaries and individual
interpersonal-sadness sensitivity slopes to examine the long-term relationship between SC
96
perfectionism and stress generation. Our findings showed that the presence of enduring
interpersonal-sadness sensitivity, as opposed to average negative social interactions or
interpersonal-NA sensitivity, explained the relationship between SC perfectionism and
interpersonal stress generation four years later. More specifically, individuals higher on SC
perfectionism were more likely to have higher levels of dependent interpersonal events in the
future because they responded to daily negative social interactions with heightened sadness.
These findings suggest that interpersonal-sadness sensitivity may serve as an important target for
future interventions that aim to reduce later stress generation for SC perfectionistic individuals.
97
References for Article 2
Achtziger, A., & Bayer, U. (2013). Self-control mediates the link between perfectionism and
stress. Motivation and Emotion, 37, 413-423. doi: 10.1007/s11031-012-9321-6
Arbuckle, J. L. (2003). Amos Users’ Guide Version 5.0. Chicago: Small Waters Corporation.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford Press.
Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck
Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8,
77-100. doi: 10.1016/0272-7358(88)90050-5
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for
measuring depression. Archives of General Psychiatry, 4, 561-571.
Békés, V., Dunkley, D. M., Taylor, G., Zuroff, D. C., Lewkowski, M., Elizabeth Foley, J., . . .
Westreich, R. (2015). Chronic stress and attenuated improvement in depression over 1
year: The moderating role of perfectionism. Behavior Therapy, 46, 478-492. doi:
10.1016/j.beth.2015.02.003
Bell, V., & Freeman, D. (2014). A pilot trial of cognitive behavioural therapy for interpersonal
sensitivity in individuals with persecutory delusions. Journal of Behavior Therapy and
Experimental Psychiatry, 45, 441-446. doi: 10.1016/j.jbtep.2014.06.001
Besser, A., & Priel, B. (2005). Interpersonal relatedness and self-definition in late adulthood
depression: Personality predispositions, and protective factors. Social Behavior and
Personality, 33, 351-382. doi: 10.2224/sbp.2005.33.4.351
98
Blatt, S. J. (1995). The destructiveness of perfectionism: Implications for the treatment of
depression. American Psychologist, 50, 1003-1020. doi: 10.1037/0003-066x.50.12.1003
Blatt, S. J., D'Afflitti, J. P., & Quinlan, D. M. (1976). Experiences of depression in normal young
adults. Journal of Abnormal Psychology, 85, 383-389. doi: 10.1037/0021-843X.85.4.383
Browne, M. W., & Cudeck, R. (1993). Alternative ways of assessing model fit. In K. A. Bollen
& J. S. Long (Eds.), Testing Structural Equation Models (pp. 136-162). Newbury Park,
CA: Sage.
Carver, C. S., & Harmon-Jones, E. (2009). Anger is an approach-related affect: Evidence and
implications. Psychological Bulletin, 135, 183-204. doi: 10.1037/a0013965
Chang, E. C. (2000). Perfectionism as a predictor of positive and negative psychological
outcomes: Examining a mediation model in younger and older adults. Journal of
Counseling Psychology, 47, 18-26. doi: 10.1037/0022-0167.47.1.18
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155-159. doi: 10.1037/00332909.112.1.155
Cohen, L. H., Gunthert, K. C., Butler, A. C., O'Neill, S. C., & Tolpin, L. H. (2005). Daily
affective reactivity as a prospective predictor of depressive symptoms. Journal of
Personality, 73, 1687-1714. doi: 10.1111/j.0022-3506.2005.00363.x
Cohen, S., Janicki-Deverts, D., & Miller, G. E. (2007). Psychological stress and disease. JAMA,
298, 1685-1687. doi: 10.1001/jama.298.14.1685
Cole, D. A., Martin, N. C., Sterba, S. K., Sinclair-McBride, K., Roeder, K. M., Zelkowitz, R., &
Bilsky, S. A. (2014). Peer victimization (and harsh parenting) as developmental
correlates of cognitive reactivity, a diathesis for depression. Journal of Abnormal
Psychology, 123, 336-349. doi: 10.1037/a0036489
99
Cole, D. A., & Maxwell, S. E. (2003). Testing mediational models with longitudinal data:
Questions and tips in the use of structural equation modeling. Journal of Abnormal
Psychology, 112, 558-577. doi: 10.1037/0021-843x.112.4.558
Coyne, J. C., & Whiffen, V. E. (1995). Issues in personality as diathesis for depression: The case
of sociotropy-dependency and autonomy-self-criticism. Psychological Bulletin, 118,
358–378. doi: 10.1037/0033-2909.118.3.358
Cranford, J. A., Shrout, P. E., Iida, M., Rafaeli, E., Yip, T., & Bolger, N. (2006). A procedure for
evaluating sensitivity to within-person change: Can mood measures in diary studies
detect change reliably? Personality and Social Psychology Bulletin, 32, 917-929.
doi: 10.1177/0146167206287721
de Mello, M. F., de Jesus Mari, J., Bacaltchuk, J., Verdeli, H., & Neugebauer, R. (2005). A
systematic review of research findings on the efficacy of interpersonal therapy for
depressive disorders. European Archives of Psychiatry and Clinical Neuroscience, 255,
75-82. doi: 10.1007/s00406-004-0542-x
Dunkley, D. M., Berg, J. L., & Zuroff, D. C. (2012). The role of perfectionism in daily selfesteem, attachment, and negative affect. Journal of Personality, 80, 633-663. doi:
10.1111/j.1467-6494.2011.00741.x
Dunkley, D. M., Blankstein, K. R., & Berg, J. L. (2012). Perfectionism dimensions and the fivefactor model of personality. European Journal of Personality, 26, 233-244. doi:
10.1002/per.829
Dunkley, D. M., & Kyparissis, A. (2008). What is DAS self-critical perfectionism really
measuring? Relations with the five-factor model of personality and depressive symptoms.
Personality and Individual Differences, 44, 1295-1305. doi: 10.1016/j.paid.2007.11.022
100
Dunkley, D. M., Ma, D., Lee, I. A., Preacher, K. J., & Zuroff, D. C. (2014). Advancing complex
explanatory conceptualizations of daily negative and positive affect: Trigger and
maintenance coping action patterns. Journal of Counseling Psychology, 61, 93-109. doi:
10.1037/a0034673
Dunkley, D. M., Mandel, T., & Ma, D. (2014). Perfectionism, neuroticism, and daily stress
reactivity and coping effectiveness 6 months and 3 years later. Journal of Counseling
Psychology, 61, 616-633. doi: 10.1037/cou0000036
Dunkley, D. M., Zuroff, D. C., & Blankstein, K. R. (2003). Self-critical perfectionism and daily
affect: Dispositional and situational influences on stress and coping. Journal of
Personality and Social Psychology, 84, 234-252. doi: 10.1037//0022-3514.84.1.234
Edwards, K. J., Hershberger, P. J., Russell, R. K., & Markert, R. J. (2001). Stress, negative social
exchange, and health symptoms in university students. Journal of American College
Health, 50, 75-79. doi: 10.1080/07448480109596010
Finch, J. F., Okun, M. A., Pool, G. J., & Ruehlman, L. S. (1999). A comparison of the influence
of conflictual and supportive social interactions on psychological distress. Journal of
Personality, 67, 581-621. doi: 10.1111/1467-6494.00066
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism.
Cognitive Therapy and Research, 14, 449-468. doi: 10.1007/bf01172967
Grzywacz, J. G., & Bass, B. L. (2003). Work, family, and mental health: Testing different
models of work-family fit. Journal of Marriage and Family, 65, 248-261. doi:
10.1111/j.1741-3737.2003.00248.x
Hammen, C. (1991). Generation of stress in the course of unipolar depression. Journal of
Abnormal Psychology, 100, 555-561. doi: 10.1037/0021-843X.100.4.555
101
Hammen, C. (2006). Stress generation in depression: Reflections on origins, research, and future
directions. Journal of Clinical Psychology, 62, 1065-1082. doi: 10.1002/jclp.20293
Hammen, C., & Brennan, P. A. (2002). Interpersonal dysfunction in depressed women:
Impairments independent of depressive symptoms. Journal of Affective Disorders, 72,
145-156. doi: 10.1016/S0165-0327(01)00455-4
Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts:
Conceptualization, assessment, and association with psychopathology. Journal of
Personality and Social Psychology, 60, 456-470. doi: 10.1037/0022-3514.60.3.456
Hewitt, P. L., & Flett, G. L. (1993). Dimensions of perfectionism, daily stress, and depression: A
test of the specific vulnerability hypothesis. Journal of Abnormal Psychology, 102, 5865. doi: 10.1037/0021-843x.102.1.58
Hewitt, P. L., & Flett, G. L. (2002). Perfectionism and stress processes in psychopathology. In G.
L. Flett & P. L. Hewitt (Eds.), Perfectionism: Theory, research, and treatment (pp. 255284): Washington, DC: American Psychological Association.
Hoyle, R. H., & Panter, A. T. (1995). Writing about structural equation models. In R. H. Hoyle
(Ed.), Structural equation modeling: Concepts, issues, and applications (pp. 158-176):
Thousand Oaks, CA: Sage Publications, Inc.
Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis:
Conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1-55. doi:
10.1080/10705519909540118
Joo, H. J., Yeon, B., & Lee, K.-U. (2012). The impact of personality traits on emotional
responses to interpersonal stress. Clinical Psychopharmacology and Neuroscience, 10,
54-58. doi: 10.9758/cpn.2012.10.1.54
102
Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal
psychotherapy of depression. New York: Basic Books.
Lakey, B., Tardiff, T. A., & Drew, J. B. (1994). Negative social interactions: Assessment and
relations to social support, cognition, and psychological distress. Journal of Social and
Clinical Psychology, 13, 42-62. doi: 10.1521/jscp.1994.13.1.42
Lindebaum, D., & Jordan, P. J. (2014). When it can be good to feel bad, and bad to feel good –
Exploring asymmetries in workplace emotional outcomes. Human Relations, 66, 1-14.
doi: 10.1177/0018726712474403
Linehan, M. (1993). Cognitive–behavioral treatment of borderline personality disorder. New
York: Guilford Press.
Luyten, P., Kempke, S., Van Wambeke, P., Claes, S., Blatt, S. J., & Van Houdenhove, B. (2011).
Self-critical perfectionism, stress generation, and stress sensitivity in patients with
chronic fatigue syndrome: Relationship with severity of depression. Psychiatry, 74, 2130. doi: 10.1521/psyc.2011.74.1.21
Mandel, T., Dunkley, D. M., & Moroz, M. (2015). Self-critical perfectionism and depressive and
anxious symptoms over four years: The mediating role of daily stress reactivity. Journal
of Counseling Psychology, 62, 703-717. doi: 10.1037/cou0000101
Marin, M.-F., Lord, C., Andrews, J., Juster, R.-P., Sindi, S., Arsenault-Lapierre, G., . . . Lupien,
S. J. (2011). Chronic stress, cognitive functioning and mental health. Neurobiology of
Learning and Memory, 96, 583-595. doi: 10.1016/j.nlm.2011.02.2016
McCrae, R. R., & Costa, P. T., Jr. (2008). The Five-Factor Theory of personality. In R. W. R.
O.P. John, and L.A. Pervin (Ed.), Handbook of personality: Theory and research (3rd
ed.). New York, NY: Guilford.
103
McQuaid, J. R., Monroe, S. M., Roberts, J. E., Kupfer, D. J., & Frank, E. (2000). A comparison
of two life stress assessment approaches: Prospective prediction of treatment outcome in
recurrent depression. Journal of Abnormal Psychology, 109, 787-791. doi: 10.1037/0021843X.109.4.787
O'Neill, S. C., Cohen, L. H., Tolpin, L. H., & Gunthert, K. C. (2004). Affective reactivity to
daily interpersonal stressors as a prospective predictor of depressive symptoms. Journal
of Social and Clinical Psychology, 23, 172-194. doi: 10.1521/jscp.23.2.172.31015
Ostiguy, C. S., Ellenbogen, M. A., Linnen, A.-M., Walker, E. F., Hammen, C., & Hodgins, S.
(2009). Chronic stress and stressful life events in the offspring of parents with bipolar
disorder. Journal of Affective Disorders, 114, 74-84. doi: 10.1016/j.jad.2008.08.006
Parrish, B. P., Cohen, L. H., & Laurenceau, J.-P. (2011). Prospective relationship between
negative affective reactivity to daily stress and depressive symptoms. Journal of Social
and Clinical Psychology, 30, 270-296. doi: 10.1521/jscp.2011.30.3.270
Powers, T. A., Zuroff, D. C., & Topciu, R. A. (2004). Covert and overt expressions of selfcriticism and perfectionism and their relation to depression. European Journal of
Personality, 18, 61-72. doi: 10.1002/per.499
Priel, B., & Shahar, G. (2000). Dependency, self-criticism, social context and distress:
Comparing moderating and mediating models. Personality and Individual Differences,
28, 515-525. doi: 10.1016/S0191-8869(99)00116-6
Schlomer, G. L., Bauman, S., & Card, N. A. (2010). Best practices for missing data management
in counseling psychology. Journal of Counseling Psychology, 57, 1-10. doi:
10.1037/a0018082
104
Shahar, G., Joiner, T. E., Jr., Zuroff, D. C., & Blatt, S. J. (2004). Personality, interpersonal
behavior, and depression: Co-existence of stress-specific moderating and mediating
effects. Personality and Individual Differences, 36, 1583-1596. doi:
10.1016/j.paid.2003.06.006
Shahar, G., & Priel, B. (2003). Active vulnerability, adolescent distress, and the
mediating/suppressing role of life events. Personality and Individual Differences, 35,
199-218. doi: 10.1016/S0191-8869(02)00185-X
Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Ecological Momentary Assessment.
Annual Review of Clinical Psychology, 4, 1-32. doi:
10.1146/annurev.clinpsy.3.022806.091415
Shih, J. H., Abela, J. R. Z., & Starrs, C. (2009). Cognitive and interpersonal predictors of stress
generation in children of affectively ill parents. Journal of Abnormal Child Psychology,
37, 195–208. doi: 10.1007/s10802-008-9267-z.
Singer, J. A. (2013). Lost in translation? Finding the person in the emerging paradigm of clinical
science: Introduction to a special issue on personality psychology and psychotherapy.
Journal of Personality, 81, 511-514. doi: 10.1111/jopy.12017
Slaney, R. B., Rice, K. G., Mobley, M., Trippi, J., & Ashby, J. S. (2001). The revised almost
perfect scale. Measurement and Evaluation in Counseling and Development, 34, 130145.
Sliwinski, M. J., Almeida, D. M., Smyth, J., & Stawski, R. S. (2009). Intraindividual change and
variability in daily stress processes: Findings from two measurement-burst diary studies.
Psychology and Aging, 24, 828-840. doi: 10.1037/a0017925
105
Starr, L. R., & Davila, J. (2008). Excessive reassurance seeking, depression, and interpersonal
rejection: A meta-analytic review. Journal of Abnormal Psychology, 117, 762–775. doi:
10.1037/a0013866
Starrs, C. J., Abela, J. R. Z., Zuroff, D. C., Amsel, R., Shih, J. H., Yao, S., Zhu, X., & Hong, W.
(2015). Predictors of stress generation in Chinese adolescents. Manuscript submitted for
publication.
Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches, evidence,
challenges. Personality and Social Psychology Review, 10, 295-319. doi:
10.1207/s15327957pspr1004_2
Tong, E. M. W. (2010). Personality influences in appraisal–emotion relationships: The role of
neuroticism. Journal of Personality, 78, 393-417. doi: 10.1111/j.1467-6494.2010.00620.x
Uliaszek, A. A., Zinbarg, R. E., Mineka, S., Craske, M. G., Griffith, J. W., Sutton, J. M., . . .
Hammen, C. (2012). A longitudinal examination of stress generation in depressive and
anxiety disorders. Journal of Abnormal Psychology, 121, 4-15. doi: 10.1037/a0025835
Vrshek-Schallhorn, S., Stroud, C. B., Mineka, S., Hammen, C., Zinbarg, R.E., Wolitzky-Taylor,
K., & Craske, M. G. (2015). Chronic and episodic interpersonal stress as statisticially
unique predictors of depression in two samples of emerging adults. Joural of Abnormal
Psychololgy. Advance online publication. doi: 10.1037/abn0000088
Watson, D., & Clark, L. A. (1994). The PANAS–X: Manual for the Positive and Negative Affect
Schedule–expanded form. Iowa City: University of Iowa.
Watson, D., Clark, L. A., & Stasik, S. M. (2011). Emotions and the emotional disorders: A
quantitative hierarchical perspective. International Journal of Clinical and Health
Psychology, 11, 429-442.
106
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures
of positive and negative affect: The PANAS scales. Journal of Personality and Social
Psychology, 54, 1063-1070. doi: 10.1037/0022-3514.54.6.1063
Weissman, A. N., & Beck, A. T. (1978). Development and validation of the Dysfunctional
Attitude Scale: A preliminary investigation. Paper presented at the 62nd Annual Meeting
of the American Educational Research Association, Toronto, Ontario, Canada.
Zuroff, D. C., Mongrain, M., & Santor, D. A. (2004). Conceptualizing and measuring personality
vulnerability to depression: Comment on Coyne and Whiffen (1995). Psychological
Bulletin, 130, 489-511. doi: 10.1037/0033-2909.130.3.489
107
Table 1
Intercorrelations, Means, and Standard Deviations of the Perfectionism, Depression, Interpersonal Sensitivity, Aggregated Negative
Social Interactions, and Episodic Stress Measures
___________________________________________________________________________________________________________
Variables
1
2
3
4
5
6
7
8
9
10
11
12
13
14
___________________________________________________________________________________________________________
1. T1 SC Perfectionism
--
2. T1 PS Perfectionism
.55***
--
3. T1 Depressive Sx
.62***
.23**
--
4. M6 Int-Sad Sensitivity
.22**
.18*
.16
5. M6 Int-NA Sensitivity
.07
.08
.12
6. M6 Agg. NegSocInt
.34**
.14
.38***
7. Y3 Int-Sad Sensitivity
.36***
.18*
.21*
8. Y3 Int-NA Sensitivity
-.09
.05
-.12
9. Y3 Agg. NegSocint
.37***
.18*
.48***
10. Y3 Depressive Sx
.54***
.20*
.68**
11. Y4 Dep. Int. Stress
.24**
.22**
.18*
-.54***
.05
.33***
.21*
-.08
-.21*
--
.12
.05
.28**
-.26**
-.19*
.81***
.04
-.06
.13
.14
-.38***
--
.09
-.35***
--
.25**
.21*
-.17*
.34***
--
.19
.29***
.11
.12
.14
--
12. Y4. Dep. Nonint. Stress
-.04
.02
-.12
.05
-.09
.04
.10
.01
-.01
.02
-.08
--
13. Y4 Indep. Int. Stress
14. Y4 Indep. Nonint. Stress
-.05
.02
-.01
.07
.03
-.01
-.08
-.04
.04
-.06
-.15
.10
-.15
-.01
.03
.01
-.02
.04
-.06
-.02
-.05
.04
-.21*
-.21*
--.12
M
.00
.01
9.27
-.00
-.00
20.73
-.00
-.01
22.01
9.56
2.24
1.48
1.37
2.25
S.D.
.10
.10
7.38
.02
.04
21.41
.02
.02
24.30
7.74
2.49
2.20
2.25
2.57
--
__________________________________________________________________________________________________________
Note. n = 145.
T1 = Time 1. M6 = Month 6. Y3 = Year 3. Y4 = Year 4. SC = Self-Critical. PS = Personal Standards. Sx = Symptoms.
Int-Sad = Interpersonal-Sadness. Int-NA = Interpersonal-NA. Agg. NegSocInt. = Aggregated Negative Social
Interactions. Dep. = Dependent. Indep. = Independent. Int. = Interpersonal. Nonint. = Noninterpersonal.
* p < .05; ** p < .01; *** p < .001
108
Figure 1. Hypothesized model relating Time 1 self-critical perfectionism, Time 1 and Year 3
depressive symptoms, Month 6 and Year 3 interpersonal-sadness sensitivity, and Year 4
dependent interpersonal episodic stress.
Time 1
Self-Critical
Perfectionism
Month 6
InterpersonalSadness
Sensitivity
Time 1
Depressive
Symptoms
Year 3
InterpersonalSadness
Sensitivity
Year 3
Depressive
Symptoms
Year 4
Dependent
Interpersonal
Stress
109
Figure 2. Standardized parameter estimates of the final structural model relating Time 1 selfcritical perfectionism, Time 1 and Year 3 depressive symptoms, Month 6 and Year 3
interpersonal-sadness sensitivity, and Year 4 dependent interpersonal episodic stress. The
residual arrows denote the proportion of variance in the measured variable that was
unaccounted for by other variables in the model. Significant estimates are shown in solid black
and nonsignificant estimates (p > .05) in dashed gray
Note. * p < .05; ** p < .01; *** p < .001.
Time 1
Self-Critical
Perfectionism
.31**
.20*
.62***
.04
.95
Month 6
InterpersonalSadness
Sensitivity
.26***
Year 3
InterpersonalSadness
Sensitivity
.03
-.02
Time 1
Depressive
Symptoms
.81
.55***
.19*
.27***
.91
.51
Year 3
Depressive
Symptoms
.08
Year 4
Dependent
Interpersonal
Stress
110
Bridge to Article 3
Articles 1 and 2 aimed to answer questions regarding longitudinal explanatory mechanisms
of the relationship between SC perfectionism and negative outcomes in a community sample
over a period of four years. Results showed that stress reactivity mediated the relationship
between SC perfectionism and depressive and anxiety symptoms over a period of four years, and
interpersonal sensitivity mediated the relationship between SC perfectionism and interpersonal
stress generation four years later. Article 3 aimed to further extend our understanding of the
relationship between SC perfectionism and distress outcomes by examining moderator
hypotheses and by including a physiological measure of stress. Article 3 focused on the role of
emotional reactivity and cortisol activity in the relationship between SC perfectionism and
depression in a clinical sample. The goal of Article 3 was to better identify under which
conditions higher SC perfectionism most strongly relates to depression in a sample of clinically
depressed outpatients over a one-year period by examining both emotional reactivity and cortisol
activity as important moderators of this relationship.
111
Article 3
Self-Critical Perfectionism and the Maintenance of Depression Over One Year: The Moderating
Role of Daily Stress-Sadness Reactivity and the Cortisol Awakening Response
Tobey Mandela,b, David M. Dunkleya,b, Maxim Lewkowskia,b, David C. Zuroffb,
Sonia Lupiend, Robert-Paul Justerb,d, N. M. K. Ng Ying Kinb,e, Elizabeth Foleya,b,
Gail Myhrb,c, and Ruta Westreicha,b
a
Lady Davis Institute - Jewish General Hospital, Montreal, Canada
b
c
McGill University Health Centre, Montreal Canada
d
e
McGill University, Montreal, Canada
Université de Montréal, Montreal Canada
Douglas Hospital Research Centre, Montreal, Canada
Mandel, T., Dunkley, D. M., Lewkowski, M., Zuroff, D. C., Lupien, S., Juster, R., Ng Ying Kin,
N. M. K., Foley, E., Myhr, G., & Westreich, R. (In preparation). Self-critical perfectionism
and the maintenance of depression over one year: The moderating role of daily stresssadness reactivity and the cortisol awakening response.
112
Abstract
This study of depressed outpatients (N = 43) examined daily stress-sadness reactivity and
the cortisol awakening response (CAR) as moderators of the relationship between self-critical
(SC) perfectionism and depression over one year. Participants completed perfectionism measures
at baseline (Time 1), daily diaries and salivary sampling six months later (Time 2), and an
interviewer-rated depression measure at Time 1, Time 2, and one year after baseline (Time 3).
Hierarchical multiple regression analyses of moderator effects demonstrated that patients with
higher SC perfectionism and higher levels of daily stress-sadness reactivity (i.e., greater
increases in daily sadness in response to increases in daily stress) had less improvement in
depressive symptoms at Time 3 relative to those of other patients, adjusting for the effects of
Time 1 and Time 2 depression. Furthermore, higher SC perfectionism in conjunction with an
elevated CAR predicted higher levels of depression at Time 3. In addition, lower SC
perfectionism in combination with higher levels of stress-sadness reactivity/CAR was associated
with the lowest levels of depression at Time 3. These findings highlight the importance of
targeting dysfunctional self-critical characteristics that exacerbate the impact of heightened
stress-sadness reactivity and CAR in order to generate better treatment outcomes for patients
with higher SC perfectionism.
113
Self-Critical Perfectionism and the Maintenance of Depression Over One Year: The
Moderating Role of Daily Stress-Sadness Reactivity and the Cortisol Awakening Response
Depressive disorders are the second leading cause of disease burden worldwide (Ferrari
et al., 2013). Moreover, the percentage of depression recurrence ranges between 35% in the
general population to 85% in mental health care facilities (Hardeveld, Spijker, De Graaf, Nolen,
& Beekman, 2010). Thus, developing a better understanding of which characteristics relate to the
maintenance of depression will be crucial in preventing the chronicity of this serious illness.
Perfectionism is an important personality factor that has been shown to relate to the
development, maintenance, and course of depression (Békés et al., 2015; Flett & Hewitt, 2002).
Perfectionism is a multidimensional construct that has been conceptualized and measured
in a variety of ways (Blatt, D'Afflitti, & Quinlan, 1976; Frost, Marten, Lahart, & Rosenblate,
1990; Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991; Slaney, Rice, Mobley, Trippi, & Ashby,
2001; Weissman & Beck, 1978). A significant development in our understanding of the
perfectionism construct indicates that perfectionism is composed of two higher-order
dimensions, namely personal standards (PS) and self-critical (SC) perfectionism (Stoeber &
Otto, 2006). PS perfectionism is the setting and pursuing of high standards and goals for oneself.
Alternatively, SC perfectionism involves chronic, intense self-scrutiny, ongoing concerns over
mistakes, and severely critical views of oneself that are associated with preoccupation regarding
others’ disapproval and criticism (Dunkley, Zuroff, & Blankstein, 2003). Prior findings have
demonstrated that, in contrast to PS, SC perfectionism is more strongly associated with
depressive symptoms over time (Mandel, Dunkley, & Moroz, 2015; Stoeber & Otto, 2006). In
addition, SC perfectionism has been shown to be relatively stable over time (Zuroff, Mongrain,
& Santor, 2004) and has been found to negatively contribute to the therapeutic process as well as
114
treatment outcomes (Blatt & Zuroff, 2005; Kannan & Levitt, 2013). Although SC perfectionism
is an important personality factor related to the maintenance of depression, little research has
highlighted under which conditions this is most likely to occur. The present study examined
daily emotional reactivity to stress and cortisol activity as potential moderating mechanisms that
contribute to the maintenance of depression over time for these vulnerable individuals in the
hopes of developing better treatment strategies for future interventions.
1.1. SC Perfectionism and Stress-Sadness Reactivity in Depression
According to the perfectionism diathesis-stress model, SC perfectionistic individuals are
most at risk for the development of depressive symptoms when they experience high levels of
stress (Flett, Hewitt, Blankstein, & Mosher, 1995). Research has shown that SC perfectionism
dimensions in conjunction with stress predict depressive symptoms over time in both nonclinical
(Chang, 2000; Enns & Cox, 2005) as well as clinical samples (Békés et al., 2015; Hewitt, Flett,
& Ediger, 1996). Moreover, depressed patients with higher levels of SC perfectionism facets,
compared to low, are more vulnerable to future depressive episodes following treatment when
they encounter high levels of stress (Zuroff & Blatt, 2002). In terms of longitudinal findings,
recent findings based on the same sample as the current study showed that SC perfectionism
interacted with chronic stress to predict depression one year later (Békés et al., 2015).
The above studies have primarily employed between-persons designs, which test whether
perfectionism dimensions in conjunction with varying levels of stress predict differences in
depression. Though prior research has emphasized the presence of stress as an important
moderator of the relationship between SC perfectionism and depression, theory and research
suggest that an individual’s reaction to a stressor represents a better predictor of depression than
the stressor itself (Beck, Rush, Shaw, & Emery, 1979; Mandel et al., 2015). Beck and
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colleagues’ theory of depression emphasizes that depression is partially maintained by an
individual’s emotional response to stress, such that cognitive biases interfere with the ability to
regulate emotions in the presence of stressful situations, making it difficult to overcome
depressive symptomatology (Alford & Beck, 1997; Gunthert, Cohen, Butler, & Beck, 2005).
Thus, it is possible that stress-affect reactivity (i.e. the relationship between an individual’s daily
stress appraisals and corresponding mood) may play an important role in the relationship
between SC perfectionism and depression maintenance. Within-person designs help to
investigate this, as they assess multiple instances of individual fluctuations in daily stress and
affect, which are needed in order to identify an individual’s typical emotional reaction to stress.
Higher levels of stress-affect reactivity have been shown to predict both the presence of a
major depressive disorder over a period of approximately 14 months, controlling for baseline
levels of depression (Wichers et al., 2009), as well as less improvement in depression throughout
treatment (Gunthert et al., 2005). Further, recent research has demonstrated that stress-sadness
reactivity (i.e. the dynamic coupling between daily stress and sadness in particular) explains the
relationship between SC perfectionism and depressive and anxious symptoms over four years in
a community sample (Mandel et al., 2015). By contrast, other research found no association
between stress-affect reactivity and major depressive disorder (MDD) over time (Wichers et al.,
2010). Given these mixed findings, we tested the possibility that heightened stress-sadness
reactivity has a more adverse impact on the maintenance of depression for high SC
perfectionistic patients than low SC perfectionistic patients.
1.2. SC Perfectionism and Cortisol in Depression
Research has also used biomarkers of psychological stress in order to further clarify the
link between stress and depression. The hypothalamus-pituitary-adrenal (HPA) axis is involved
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in the physiological stress response, and one such measure of physiological stress is salivary
cortisol (Hellhammer, Wüst, & Kudielka, 2009). Cortisol is a stress hormone that plays an
important role in physical and psychological health, and is known to provide feedback to neural
structures that are involved in emotion and cognition (Rodrigues, LeDoux, & Sapolsky, 2009).
Two well-supported methods in which to measure cortisol activity are referred to as
diurnal cortisol secretion and the cortisol awakening response (CAR; Pruessner et al., 1997).
Diurnal cortisol secretion refers to the overall pattern of cortisol release throughout the day, also
referred to as area under the curve with respect to ground (AUCg; Pruessner, et al., 2003). The
relationship between cortisol release and mood has been mixed, such that depression has been
linked to both hyper- and hypoactivity of the HPA axis as demonstrated by increased or
decreased diurnal cortisol levels (Gold, Licinio, Wong, & Chrousos, 1995; Pfohl, Sherman,
Schlechte, & Winokur, 1985; Vreeburg et al. 2013). The CAR is a measure of cortisol that is
released upon awakening, and may provide an energetic “boost” that helps individuals to prepare
for upcoming daily demands (Adam et al., 2010; Chida & Steptoe, 2009; Fries, Dettenborn, &
Kirschbaum, 2009; Hoyt, Zeiders, Ehrlich, Adam, 2016). An elevated CAR has been considered
to be adaptive at times (Clow, Hucklebridge, Stalder, Evans & Thorn, 2010), and momentary
increases in cortisol have been related to increases in activeness, alertness, and relaxation (Hoyt
et al., 2016). Further, recent research found that the CAR had no relation to depression over a
period of three years (Carnegie et al., 2014). On the other hand, other findings have shown a link
between the CAR and depressive symptoms, such that an elevated CAR was found to be
associated with major depression over a period of 2.5 years, as well as the recurrence of major
depressive episodes over time (Vrshek-Schallhorn et al., 2013). Furthermore, a larger CAR was
associated with increased likelihood of having a major depressive episode one year later, and
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was shown to be an independent predictor of depression over and above life stress (Adam et al.,
2010). These mixed findings suggest that there may be individual differences that help determine
whether cortisol levels have an adaptive or adverse impact on the maintenance of depression.
Research has demonstrated a link between SC perfectionism and dysregulated cortisol
activity, with some research noting a link between higher perfectionism scores and greater
cortisol response to a psychosocial stress (Wirtz et al., 2007), whereas others have found that
maladaptive perfectionism relates to a blunted cortisol response to stress (Kempke, Luyten,
Mayes, Van Houdenhove, & Claes, 2016; Richardson, Rice, & Devine, 2014). Given that
research has demonstrated that high SC perfectionism in conjunction with higher levels of
perceived stress predicts depression (Chang, 2000; Enns & Cox, 2005), higher levels of cortisol
in combination with greater SC perfectionism may predict higher levels of depression
maintenance as well. Research has yet to examine the impact of dysregulated cortisol activity on
the maintenance of depression for SC perfectionists. Higher levels of diurnal cortisol or a greater
CAR may provide an energetic boost for certain depressed patients that helps to lessen the
degree of their depressed mood (Hoyt, et al., 2016). On the other hand, greater diurnal cortisol or
a higher CAR may represent high SC perfectionists’ helpless response to daily demands because
of their perceived inability to sufficiently cope in the face of stressors, leading to withdrawal and
avoidant coping, which may then contribute to depression over time (e.g., Dunkley, Mandel, et
al., 2014).
1.3. Present Study
In order to examine these questions further, the present study examined daily stresssadness reactivity and cortisol activity as moderators of the prospective relationship between SC
perfectionism and depression maintenance over time. In order to assess this, we tested clinically
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depressed outpatients over a one year period at three time-points: (1) measures of perfectionism
and depressive symptoms were collected at Time 1; (2) stress-sadness reactivity, diurnal cortisol
and CAR, and depressive symptoms were measured at Time 2 six months later; and (3)
depressive symptoms were again collected at Time 3 one year following baseline.
Our main hypotheses were that high SC perfectionism in conjuction with higher levels of
stress-sadness reactivity would predict depression maintenance over one year in outpatients
undergoing therapy. Further, we expected that high SC perfectionism combined with elevated
levels of diurnal cortisol and/or the CAR would predict ongoing depression in depressed
outpatients. Lastly, given that there is some evidence to suggest that PS perfectionism interacts
with stress to predict negative outcomes (Békés et al., 2015, Enns & Cox, 2005), we also
examined whether PS perfectionism interacts with stress-sadness reactivity, diurnal cortisol
and/or the CAR to predict depression maintenance.
2. Methods
2.1. Participants
The present study presents additional analyses of data from the same sample of depressed
outpatients used in Békés et al., (2015). The current study was comprised of a sample of 43
English- and French-speaking outpatient adults between the ages of 18-65, who had a primary
diagnosis of current unipolar major depression (MDD) according to the Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric
Association, 2000). Participants were referred for treatment at one of two major teaching
hospitals in an eastern North American city and were eligible if they had not had any change in
medication for a minimum of four weeks prior to the study.
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Participants were administered the Structured Clinical Interview for the DSM-IV, Axis I
Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 2002) in order to ensure a reliable and
comprehensive DSM-IV Axis I diagnosis. Exclusion criteria consisted of comorbid psychiatric
disorders (bipolar disorder, psychotic subtypes of depression, current substance abuse, past or
present schizophrenia or schizophreniform disorder, organic brain syndrome, and mental
retardation). In addition, participants who were undergoing concurrent psychotherapy or who
required hospitalization due to the possibility of imminent suicide or psychosis were excluded.
Out of the 65 participants who met criteria for inclusion in the study, 43 completed
perfectionism measures at Time 1, a minimum of five daily diaries at Time 2 six months later, a
minimum of one day of salivary cortisol samples at Time 2, and interviewer-rated depression
measures at Time 1, Time 2, and Time 3 one year after baseline. The final sample of 43
participants (30 women, 13 men) completed their Time 2 measures approximately six months
later (M = 6.52, SD = .75), and their Time 3 measures approximately one year following baseline
measures (M = 12.67 months, SD = 1.17). One participant who completed Time 2 daily diaries
did not complete Time 2 salivary cortisol samples, and four participants who completed Time 2
salivary cortisol samples did not complete a sufficient number of Time 2 daily dairies. Out of the
39 participants who completed daily diaries, two were missing one day of daily dairies, and three
were missing two nonconsecutive days of daily dairies (e.g., days two and six). Out of the 42
participants with cortisol data, two were missing one day of cortisol measures.
The mean age of the sample at Time 1 was 40.65 years (SD = 10.63). Participants were
primarily of European descent (70%), with 7% African, 7% West Indian, 3% East Indian, 3%
Middle Eastern, 3% Aboriginal, and 4% unspecified. Thirty-seven participants (25 female, 12
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male) completed the English version of the questionnaires and six participants (5 female, 1 male)
completed the French version of the questionnaires.
Eighty-six percent of participants reported taking concurrent psychiatric medication.
Ninety-one percent of participants met concurrent SCID-I criteria for moderate to severe
depression severity, and 88% had a previous major depressive episode. Sixty-five percent of
participants met SCID-I criteria for at least one co-morbid Axis I disorder. Fourteen percent of
participants met SCID-I criteria for dysthymia, 23% met criteria for social phobia, 21% met
criteria for panic disorder, 21% met criteria for post-traumatic stress disorder, 12% met criteria
for generalized anxiety disorder, 12% met criteria for anxiety disorder not otherwise specified,
7% met criteria for agoraphobia, 2% met criteria for obsessive-compulsive disorder, 2% met
criteria for eating disorder not otherwise specified, and 2% met criteria for a pain disorder.
2.2. Protocol
Participants were all referred for Cognitive Behavioral Therapy (CBT), however they
completed a varying number of therapy sessions (M = 15.77, SD = 8.37, range: 1-30). Prior to
their hospital visit, at Time 1 (baseline), participants completed measures of perfectionism at
home for 60-90 minutes. Following this, participants were invited for their first hospital visit,
where they completed the SCID-I and the interviewer-rated 17-item Hamilton Rating Scale for
Depression (HAM-D; Hamilton, 1960) for a period of three to four hours. Licensed clinical
psychologists, with doctoral degrees that involved extensive training in diagnostic interviewing,
administered both the SCID-I and the HAM-D. In addition, the ratings from these interviews
were discussed and reviewed in consultation between the interviewers for a total of
approximately 15 hours. At Time 2 (six months later), participants were invited back to the
hospital to complete the HAM-D for the second time. Participants were also provided seven days
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of daily dairies to complete and were asked to provide salivary cortisol samples on Day 1 and
Day 7. At Time 3 (one year after baseline), participants were again invited back to the hospital to
complete their third and final HAM-D measure. Participants were compensated a total of $200
for completing the three assessments.
2.3. Psychological measures
Given that the population was bilingual, English participants completed the English
version of the questionnaires and French participants completed the French version. The French
versions of the Time 1 perfectionism and Time 2 stress appraisals and affect measures have been
found to have similar internal consistencies and validity as their English counterparts (Dunkley,
Blankstein, & Berg, 2012; Dunkley & Kyparissis, 2008; Dunkley, Mandel, & Ma, 2014).
2.3.1. Perfectionism. SC and PS dimensions of perfectionism were derived from the
following questionnaires: the 45-item Multidimensional Perfectionism Scale (Hewitt et al.,
1991), the 35-item Multidimensional Perfectionism Scale (Frost et al., 1990), the 23-item Almost
Perfect Scale-Revised (Slaney et al., 2001), the 66-item Depressive Experiences Questionnaire
(Blatt et al., 1976), and the 40-item Dysfunctional Attitude Scale (Weissman & Beck, 1978). The
SC and PS perfectionism measures were chosen based on previous factor analyses (Dunkley,
Lewkowski et al., 2016; Stoeber & Otto, 2006). SC perfectionism was based on DEQ selfcriticism, DAS self-criticism, FMPS concern over mistakes, HMPS socially prescribed
perfectionism and APS-R Discrepancy. PS perfectionism was composed of HMPS self-oriented
perfectionism, FMPS personal standards, and APS-R high standards. As was done in previous
studies (Békés et al., 2015; Dunkley, Berg, & Zuroff, 2012; Mandel et al., 2015), the DEQ, DAS,
FMPS, HMPS and APS-R measures were standardized and saved as z-scores and then averaged
together to create the relevant SC and PS perfectionism composite scores.
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The reliability and validity of the DEQ (Zuroff et al., 2004), DAS (Dunkley &
Kyparissis, 2008; Powers, Zuroff, & Topciu, 2004), APS-R (Slaney et al., 2001), HMPS (Hewitt
et al., 1991), and FMPS (Frost et al., 1990) measures have been well-established. Coefficient
alphas for the current research for DAS self-criticism, FMPS concern over mistakes, HMPS
socially prescribed perfectionism, APS-R discrepancy, FMPS personal standards, HMPS selforiented perfectionism, and APS-R high standards were .90, .89, .90, .93, .75, .94, and .86,
respectively. The reliability for DEQ self-criticism was not calculated because it was scored
using factor weights (Zuroff et al., 2004). The internal consistencies of SC and PS perfectionism
composites were .80 and .75, respectively. Support has been found for both the convergent and
discriminant validity for the SC and PS composite scores. To elaborate, PS composites have been
associated with conscientiousness, which is in contrast to SC composites that have been
associated with neuroticism, daily stress, negative interpersonal exchanges, maladaptive coping,
and depressive symptoms in both nonclinical (Dunkley, Mandel, et al., 2014; Dunkley et al.,
2003) and clinical samples (Dunkley, Lewkowski, et al., 2016).
2.3.2. Interviewer-Rated Depressive Symptoms. Depression severity was measured
using the 17-item Hamilton Depression Rating Scale (HAM-D; Hamilton, 1960), which is the
most widely used interviewer-rated measure of depression. The HAM-D has shown good
internal consistency, with a mean alpha coefficient of .79 across various studies, and has
demonstrated higher variability of scores and greater internal consistency at lower mean
depression scores (Trajković et al., 2011). As seen in Table 1, the present study demonstrated a
similar pattern, such that internal consistency for the HAM-D increased from .59 to .93 from
Time 1 to Time 2 and then to .85 from Time 2 and Time 3, respectively, as depression scores
decreased on average from Time 1 to Time 2 and Time 3. The HAM-D has demonstrated good
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inter-rater reliability, with a pooled mean ICC of .93 for independent interviews, and this
reliability has increased throughout decades of use (Trajković et al., 2011). Although the present
study did not formally calculate inter-rater reliability for the HAM-D, as previously mentioned
the two highly trained interviewers met regularly to consult and calibrate on various interviews.
The HAM-D is sensitive to changes in depression severity and is moderately related to other
measures of depression (Katz, Shaw, Vallis, & Kaiser, 1995). For French participants, the
interview guide questions were translated into French by the bilingual interviewer and
participants were queried until sufficient information was obtained in order to rate the given
item.
2.4. Daily Diary measures
Participants were provided a package containing seven stamped and addressed envelopes,
each containing a daily diary questionnaire booklet. Participants were explained in detail each
section of the daily diary, and were instructed to complete one daily diary at bedtime, starting
that evening, consecutively for the following seven nights. The daily dairy booklet included
questionnaires measuring daily affect and stress appraisals. Participants were then asked to mail
the envelope with the completed daily diary the following morning. Participants were
encouraged to complete their diaries every evening. If for any reason this was not possible,
participants were asked to complete them as soon as possible the following morning. In addition,
participants were contacted on days three and five to remind them to complete the daily
measures
2.4.1. Daily Affect. Present day levels of sadness were measured using The Positive and
Negative Affect Schedule-Expanded (Watson & Clark, 1994) 5-item scale. Good within- and
between-persons reliability and validity has been established in evaluating this form of daily
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affect (Dunkley, Mandel, et al., 2014; Mandel et al., 2015), and the within- and between- person
reliabilities, calculated using Cranford and colleagues’ (2006) procedure, in the present study
were .84 and .94, respectively.
2.4.2. Event Appraisals. Participants were asked to describe their most bothersome
event of today by providing information about what specifically happened, where the event took
place, and why the event was important. The event could be something that had happened in the
past, something that was happening today, or something that they were anticipating happening in
the future. After describing the event itself, participants were asked to rate the event on a number
of aspects: “how unpleasant was the event or issue to you?” (1 = not at all to 11 = exceptionally),
“for how long were you bothered by the event or issue?” (1 = a very brief amount of time to 7 =
a very large amount of time), and “how stressful was the event or issue for you?” (1 = not at all
to 11 = exceptionally). In order to calculate event stress, the length of the appraisal item score
was rescaled to be on an 11-point scale as opposed to a 7-point scale, and the average of the three
appraisal items (i.e. unpleasantness, length, and stressfulness) was calculated in order to establish
an event stress score that reflected both the degree and duration of difficulty of the participant’s
most bothersome event of the day. The most bothersome daily event measure has been found to
be internally consistent as well as valid (Dunkley, Mandel, et al., 2014; Dunkley et al., 2003).
Using Cranford and colleagues’ (2006) procedure, the within- and between-persons reliabilities
for event stress .82 and .75, respectively.
2.4.3 Stress-sadness reactivity. In order to create variables to assess daily stress-sadness
reactivity, we conducted multilevel modeling using SAS PROC MIXED (Version 9.2) and
maximum likelihood estimation. Specifically, within-person daily variability in sadness was
predicted from within-person fluctuations in event stress (with the slope modeled as randomly
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varying across participants). The individual slopes were empirical Bayes estimates, and the
variance associated with these slopes was significant. The resulting regression coefficient
represents a slope for each participant, which was used as a between-persons stress-sadness
reactivity variable in the hierarchical multiple regression analyses.
2.5. Cortisol Collection
Participants were provided with a saliva kit to take home and were asked to provide a
sample of their saliva at five specific times during each target day. Participants were given
detailed instructions, both written and verbal, for the salivary cortisol collection. They were
asked to not brush their teeth prior to providing the sample, in order to avoid food intake prior to
testing. In order to verify each participant’s degree of compliance with the requested cortisol
samples, we utilized the Medication Event Monitoring System (MEMS®). The MEMS® is a wellvalidated electronic monitoring system that allows researchers to analyze and monitor
participant’s compliance with the prescribed time of saliva sampling in the natural environment.
The system is comprised of two parts: a standard plastic vial with threaded opening and a closure
for the vial that contains a micro-electronic circuit that registers times when the closure is opened
and when it is closed. Once the sampling is done, the events stored in the MEMS® can be
transferred through the MEMS® communicator to a Windows-based computer. Software then
analyzes and displays the computed parameters of the participant’s compliance. The results
obtained with the MEMS® are widely regarded as the gold standard measure of patient
compliance (Kudielka, Broderick, & Kirschbaum, 2003). After collecting their saliva samples,
participants were asked to store them in their home freezers prior to dropping them off to a
member of the research team prior to their next CBT session. Assaying salivary cortisol was
performed in the laboratory of Dr. N.M.K. Ng Ying Kin at the Douglas Hospital Research
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Centre. The ICN radioimmunoassay kit for plasma cortisol was obtained from Medicorp
(Montreal), and modified for the determination of salivary cortisol.
2.5.1. Diurnal cortisol. On Days 1 and 7 of the diary collection, participants were asked
to provide saliva samples at awakening, 30 minutes after awakening, 14h00, 16h00, and before
bedtime. These time points have been used in previous research in order to measure diurnal
HPA-axis functioning (Juster et al., 2016). Diurnal cortisol levels were measured using area
under the curve with respect to ground (AUCg) formula, as recommended by Pruessner et al.
(2003).
2.5.2. Cortisol awakening response. Morning cortisol increase was measured by
calculating the CAR, which allows for a more stable, noninvasive measurement of HPA activity
that does not rely on stressor tasks that may vary between studies (Carnegie et al., 2014; Chida &
Steptoe, 2009). On Days 1 and 7 of the diary collection, participants’ saliva at the time of
awakening and 30 minutes after awakening was used to assess the CAR. In order to calculate the
CAR value, daily cortisol levels at 30 minutes (M = 34.20, SD = 11.40 minutes) post awakening
were subtracted from cortisol levels at awakening. The average of the two CAR levels from Days
1 and 7 were used in order to represent each participant’s CAR level (Therrien et al., 2008).
3. Results
3.1. Descriptive Statistics
The means, standard deviations and internal consistencies for the Time 1 SC and PS
perfectionism, Time 2 stress-sadness reactivity, diurnal cortisol, and CAR, and Time 1, 2 and 3
depression measures are presented in Table 1. As reported in Békés et al., (2015), depression
scores demonstrated a significant decrease between Time 1 and Time 2, F(1, 42) = 28.15, p <
.001, Time 1 and Time 3 F(1, 42) = 43.39, p < .001, and finally Time 2 and Time 3, F(1, 42) =
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4.32, p < .001. Results from T-tests comparing the means for the Time 1 depression and
personality measures showed no significant differences between the 22 participants who did not
complete all three time points and the 43 who did complete all three time points. In addition,
results from T-tests also showed no significant differences in Time 3 depression scores between
men versus women, participants with versus without a history of major depression, participants
with versus without a co-morbid Axis I disorder, and participants who were versus were not
taking psychiatric medication at the beginning of the study. Further, results from T-tests also
indicated that there were no significant differences on either of the cortisol measures between
participants who were or were not taking psychiatric medication.
3.2. Intercorrelations
The relations between Time 1 SC and PS perfectionism, Time 1, Time 2, and Time 3
HAM-D for the present sample were previously reported by Békés et al., (2015).
Intercorrelations shown in Table 1 indicate that Time 1 SC perfectionism was significantly
correlated with Time 3 depression scores only, whereas Time 1 PS perfectionism did not
correlate significantly with any of the stress-sadness reactivity, cortisol, or depression variables
in the analyses. Time 2 daily stress-sadness reactivity was moderately to strongly related to Time
1, Time 2, and Time 3 depression scores, as well as Time 2 CAR. Time 2 diurnal cortisol and
CAR were strongly related, but neither cortisol variable was significantly related to Time 2 or
Time 3 depression.
3.3. Hierarchical Multiple Regression Analyses
Hierarchical multiple regression analyses were performed in order to examine whether
Time 2 stress-sadness reactivity, diurnal cortisol, and CAR moderate the relation between Time
1 SC perfectionism and Time 3 depression scores. All predictor variables were standardized.
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Time 1 SC perfectionism was combined into interaction terms with each Time 2 variable (stresssadness reactivity, diurnal cortisol, CAR) predicting T3 HAM-D. Each variable was entered into
the hierarchical multiple regression one step at time, which is the method used by Hewitt, Flett,
and colleagues to examine moderator hypotheses (Hewitt et al., 1996) and incorporates an
incremental partitioning of variance (Cohen, Cohen, West, & Aiken, 2003).
In order to control for baseline depression scores, Time 1 and Time 2 depression scores
were entered in the first and second block of the hierarchical multiple regression. In order to
control for the main effect of the predictors prior to testing the relevant interaction, the Time 2
stress-sadness reactivity/diurnal cortisol/CAR variable was entered in the third block and the
Time 1 SC perfectionism scores were entered in the fourth block. The fifth and final block of the
regression included the relevant interaction term between Time 1 SC perfectionism and the Time
2 stress-sadness reactivity/diurnal cortisol/CAR variable. As shown in Table 2, Time 1 HAM-D
scores predicted a nonsignificant amount of unique variance in Time 3 HAM-D scores, whereas
Time 2 HAM-D scores accounted for a significant amount of additional variance in Time 3
HAM-D scores (p < .01) over and above Time 1 HAM-D depression scores. Results for the SC
perfectionism, stress-sadness reactivity, and cortisol variables are described below.
3.3.1. SC perfectionism and daily stress-sadness reactivity predicting depression. As
displayed in Table 2, Time 2 stress-sadness reactivity accounted for a nonsignificant amount of
unique variance in Time 3 HAM-D depression scores. Time 1 SC perfectionism predicted a
significant 11% of additional variance (p < .05) in Time 3 depression scores, above and beyond
Time 1 and Time 2 HAM-D depression scores. Lastly, Time 1 SC perfectionism interacted with
Time 2 stress-sadness reactivity to predict a significant 12% of unique variance (p < .01) in Time
3 HAM-D depression scores. Effect sizes were calculated using Cohen’s f2 test, which
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demonstrated that the interaction between Time 1 SC perfectionism and Time 2 stress-sadness
reactivity predicting Time 3 HAM-D had a moderate effect size of .14 (Cohen, 1988). When
entering PS as opposed to SC in the fourth block, PS perfectionism predicted a significant 8% of
unique variance (p < .05) in Time 3 HAM-D scores. However, the interaction between PS and
Time 2 stress-sadness reactivity was entered into the fifth block and predicted a nonsignificant
amount of incremental variance (ΔR2 = .003, p = .67).
In keeping with recommendations by Cohen et al. (2003), the significant interaction was
interpreted by calculating the simple slope at each level of the independent variables, which was
represented as one standard deviation above or below the mean. As demonstrated in Figure 1, for
patients with high levels of Time 2 stress-sadness reactivity, there was a significant positive
relation between Time 1 SC perfectionism and Time 3 depression scores, slope = 6.59, t(33) =
4.20, p < .01. In contrast, the relationship between Time 1 SC perfectionism and Time 3
depression scores was nonsignificant for patients with low levels of Time 2 stress-sadness
reactivity.
3.3.2. SC perfectionism, diurnal cortisol, and CAR predicting depression. Time 2
diurnal cortisol predicted a nonsignificant amount of incremental variance (ΔR2 = .01, p = .54) in
Time 3 HAM-D depression scores. Time 1 SC perfectionism accounted for a significant 8% of
additional variance (p < .05) in Time 3 depression scores, above and beyond Time 1 and Time 2
HAM-D scores. However, Time 1 SC perfectionism did not interact with Time 2 diurnal cortisol
to predict changes in Time 3 HAM-D depression scores (ΔR2 = .000, p = .95).
As shown in Table 2, Time 2 CAR predicted a nonsignificant amount of incremental
variance in Time 3 HAM-D depression scores. Time 1 SC perfectionism accounted for a
significant 8% of additional variance (p < .05) in Time 3 depression scores, above and beyond
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Time 1 and Time 2 HAM-D scores. Lastly, Time 1 SC perfectionism interacted with Time 2
CAR to predict a significant 14% of unique variance (p < .01) in Time 3 HAM-D depression
scores. Results of Cohen’s f2 test suggested that the interaction between Time 1 SC
perfectionism and Time 2 CAR predicting Time 3 HAM-D had a moderate effect size of .17
(Cohen, 1988). When PS replaced SC in the fourth block, PS perfectionism was found to predict
a significant 8% of unique variance (p < .05) in Time 3 HAM-D scores. Following this,
however, when PS X Time 2 CAR was entered into the fifth block, the effect was nonsignificant
(ΔR2 = .02, p = .23).
As shown in Figure 1, for patients with high levels of Time 2 CAR, there was a
significant positive relation between Time 1 SC perfectionism and Time 3 depression scores,
slope = 6.14, t(36) = 6.14, p < .01. For patients with low levels of Time 2 CAR, the relationship
between Time 1 SC perfectionism and Time 3 depression scores was nonsignificant.
4. Discussion
The present study examined the relationship between SC perfectionism and daily stresssadness reactivity and cortisol activity in predicting depression maintenance over a one-year
period. This study is the first to demonstrate links between higher SC perfectionism, emotional
reactivity, and physiological stress measures in a sample of depressed outpatients over a period
of one year. In line with our hypotheses, our first set of findings demonstrated that patients with
higher SC perfectionism and higher levels of daily stress-sadness reactivity had higher levels of
depression at Time 3 relative to those of other patients, adjusting for the effects of Time 1 and
Time 2 depression. Furthermore, SC perfectionism in combination with lower levels of stresssadness reactivity was not associated with higher levels of depression at Time 3. In addition, our
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findings show that lower SC perfectionism in conjunction with high stress-sadness reactivity
predicted the lowest levels of depression one year later.
These findings extend the perfectionism diathesis-stress model by highlighting the
importance of stress-sadness reactivity as particularly maladaptive in the relationship between
SC perfectionism and depression. These results also provide further support for Beck et al.’s
(1979) theory of depression, by emphasizing the importance of how one reacts to a stressor.
Similar results were not found for PS perfectionism, highlighting the especially maladaptive
nature of higher SC perfectionism in conjunction with daily stress-sadness reactivity. Moreover,
the discrepancy in findings between SC and PS perfectionism is consistent with previous
research highlighting that SC perfectionism represents the more maladaptive dimension of
perfectionism (Mandel et al., 2015; Stoeber & Otto, 2006). Our findings are also in line with
previous research demonstrating a link between SC perfectionism and depression maintenance
(Zuroff & Blatt, 2002), but further add to the literature by better identifying under which
conditions this relationship occurs.
A possible explanation for this finding is that high SC perfectionists tend to interpret
stressors as representing a failure of the self and a potential loss of control, which perpetuates
helplessness thinking and avoidant coping tendencies that further prolong dysphoric emotions
(Beck et al., 1979; Dunkley et al., 2003; Flett & Hewitt, 2002). Further, the presence of sadness
has also been linked to more avoidance and withdrawal behaviors (see Carver & Harmon-Jones,
2009; Lindebaum & Jordan, 2014). Thus, high stress-sadness reactivity may place high SC
perfectionists at an especially high risk of maintaining depressive symptoms over time.
Interestingly, our findings also demonstrate that high stress-sadness reactivity is
protective for those with low levels of SC perfectionism. Lower SC perfectionistic individuals, in
132
contrast to higher, may be more skilled at distancing themselves from their appraisal-emotion
responses, allowing them to better accept and cope with their difficulties in an open,
compassionate manner, as opposed to avoiding them, which may contribute to fewer depressive
symptoms over time (Gilbert & Procter, 2006; Hayes, Strosahl, & Wilson, 2012; Niles et al.,
2013). This finding might be further explained by the fact that higher levels of major depression
have been associated with a general diminishment of emotional reactivity to negative stimuli
(Rottenberg, Gross, & Gotlib, 2005). Lack of context appropriate emotional responses may be
problematic because emotional reactions serve to communicate information and to elicit
potentially helpful responses from others (Rottenberg & Vaughan, 2008). It is possible that
individuals with low SC perfectionism who have high levels of stress-sadness reactivity show the
most improvement in depression over one year because their expression of sadness in the face of
stressors helps them to communicate their needs and elicits more social engagement and support
from important others (Rottenberg & Vaughan, 2008).
Our second set of findings demonstrated that higher SC perfectionism, in conjunction
with a heightened CAR, predicted the highest level of depression maintenance over a one-year
period, adjusting for the effects of Time 1 and Time 2 depression. Our results also demonstrate
that low SC perfectionism in combination with a high CAR predicts the lowest levels of
depression. Our findings help to reconcile the previously mixed findings between the CAR and
depression (Adam et al., 2010; Carnegie et al., 2014; Vrshek-Schallhorn, 2013) by demonstrating
the heterogeneous nature of the effect of CAR. In contrast, however, diurnal cortisol activity did
not interact with SC perfectionism to predict depression over time. This suggests that an elevated
rise in cortisol in the morning, as opposed to overall stress hormone levels throughout the day,
interacts with SC perfectionism to predict depression one year later. This discrepancy between
133
results found for diurnal cortisol levels in comparison to the CAR is in line with previous
research (Adam et al., 2010; Vreeburg et al., 2013). An elevated CAR may be more detrimental
than high diurnal cortisol levels because CAR appears to be impacted by both genetic as well as
environmental influences, which together may result in particularly maladaptive outcomes for
those at risk for depression (Chida & Steptoe, 2009). Furthermore, given that research has
suggested a possible link between the CAR and preparing for upcoming daily demands (Adam et
al., 2010; Chida & Steptoe, 2009; Fries, Dettenborn, & Kirschbaum, 2009), a high CAR in high
SC perfectionists may represent potential distress because they anticipate that they are unable to
adequately cope with the upcoming demands, leading them to respond with a helplessness
orientation and avoidance, which may lead to increases in depression over time (e.g., Dunkley et
al., 2003; Dunkley, Mandel, et al., 2014).
On the other hand, an elevated CAR in low SC perfectionists’ may signal an adaptive
response as low SC perfectionists’ are able to better cope in the face of perceived daily demands
and stressors (Fries, Dettenborn, & Kirschbaum, 2009). Moreover, an elevated CAR may
provide an energetic boost that includes increases in activeness, alertness, and relaxation (Hoyt et
al., 2016), which may provide low SC perfectionists with the added energy that they need to
challenge their depressive thoughts or engage in more behavioral activation. In short, the
presence of an elevated CAR may be adaptive in certain circumstances (Clow et al., 2010),
however, the increase in stress hormone in high SC perfectionists may signal a more helpless
rather than opportunitistic response.
The clinical implications of our findings are especially important to consider, given that
previous research has noted that SC perfectionism negatively impacts treatment for depressive
symptoms (Blatt & Zuroff, 2005). The findings from our study highlight the importance of
134
taking into account personality characteristics as well as stress-sadness reactivity and the CAR in
the treatment of depression. In order to provide more effective treatment for high SC
perfectionistic patients, future interventions should target dysfunctional self-critical
characteristics (e.g., maladaptive coping, contingent self-worth beliefs) that exacerbate the
impact of heightened stress-sadness reactivity and an elevated CAR in order to generate better
treatment outcomes (Dunkley et al., 2003; Sturman, Flett, Hewitt, & Rudolph, 2009). By
targeting dysfunctional self-critical characteristics, treatment may help high SC perfectionists to
more constructively interpret heightened levels of stress-sadness reactivity and a higher CAR as
adaptive and helpful. Furthermore, cognitive restructuring that helps to minimize overemphasis
on the negative impact of daily stressors may help to reduce these exaggerated
emotional/physiological stress responses for high SC perfectionists (Niles, Mesri, Burklund,
Lieberman, & Craske, 2013). Lastly, interventions that contain acceptance and mindfulness
techniques, which provide strategies for distancing from, observing and accepting ones’
emotions, may help high SC perfectionistic patients to react less negatively when faced with
stress (Hayes, Strosahl, & Wilson, 2012; Niles et al., 2013).
4.1. Limitations and Future Directions
Though the current study advances previous literature by identifying important
moderators that help to explain the relationship between SC perfectionism and the maintenance
of depression over time, it also contains some important limitations. First, inter-rater reliability
was not established for the HAM-D interview ratings, however, high inter-rater reliability has
been found for this measure in previous research (Trajković et al., 2011). Second, our results are
based on a relatively small sample, therefore future research should aim to include a larger
clinical sample in order to assess the generalizability of our findings. Third, future research
135
should examine models that include additional explanatory mechanisms that aim to explain why
high SC perfectionists, in sharp contrast to low SC perfectionists, exhibit a maladaptive response
to stress-sadness reactivity and a heightened CAR. Possible additional mechanisms that may be
of interest include maladaptive coping, such as avoidance (Dunkley, Mandel, et al., 2014), versus
adaptive coping styles that focus on more mindful, self-compassion oriented coping (Gilbert &
Procter, 2006; Hayes, Strosahl, & Wilson, 2012. Lastly, future research should examine whether
our findings generalize to other clinical and nonclinical populations.
4.1. Conclusion
The present study used individual stress-sadness reactivity slopes and the cortisol
awakening response to better comprehend the relationship between SC perfectionism and
depression in a depressed sample one year later. Results demonstrated that higher SC
perfectionism predicted less improvement in depressive symptoms for individuals with high
levels of stress-sadness reactivity or a higher CAR over a period of one year. Furthermore,
findings also showed that, for lower SC perfectionists, higher stress-sadness reactivity or CAR
serve as protective mechanisms against depressive symptoms. These results are the first to
demonstrate a parallel between higher SC perfectionism, emotional reactivity and physiological
stress measures in the maintenance of depression over a one-year period in a sample of depressed
outpatients. 136
References for Article 3
Adam, E. K., Doane, L. D., Zinbarg, R. E., Mineka, S., Craske, M. G., & Griffith, J. W. (2010).
Prospective prediction of major depressive disorder from cortisol awakening responses in
adolescence. Psychoneuroendocrinology, 35, 921-931. doi:
10.1016/j.psyneuen.2009.12.007
Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York:
Guilford.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text rev.). Washington, DC: Author.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford Press.
Békés, V., Dunkley, D. M., Taylor, G., Zuroff, D. C., Lewkowski, M., Elizabeth Foley, J., . . .
Westreich, R. (2015). Chronic stress and attenuated improvement in depression over 1
Year: The moderating role of perfectionism. Behavior Therapy, 46, 478-492. doi:
10.1016/j.beth.2015.02.003
Blatt, S. J. (1995). The destructiveness of perfectionism: Implications for the treatment of
depression. American Psychologist, 50, 1003-1020. doi: 10.1037/0003-066x.50.12.1003
Blatt, S. J., D'Afflitti, J. P., & Quinlan, D. M. (1976). Experiences of depression in normal young
adults. Journal of Abnormal Psychology, 85, 383-389. doi: 10.1037/0021-843X.85.4.383
Blatt, S. J., & Zuroff, D. C. (2005). Empirical evaluation of the assumptions in identifying
evidence based treatments in mental health. Clinical Psychology Review, 25, 459-486.
doi: 10.1016/j.cpr.2005.03.001
137
Carnegie, R., Araya, R., Ben-Shlomo, Y., Glover, V., O’Connor, T. G., O’Donnell, K. J., &
Pearson, R., Lewis, G. (2014). Cortisol awakening response and subsequent depression:
Prospective longitudinal study. The British Journal of Psychiatry, 204, 137-143. doi:
10.1192/bjp.bp.113.126250
Chang, E. C. (2000). Perfectionism as a predictor of positive and negative psychological
outcomes: Examining a mediation model in younger and older adults. Journal of
Counseling Psychology, 47, 18-26. doi: 10.1037/0022-0167.47.1.18
Chida, Y., & Steptoe, A. (2009). Cortisol awakening response and psychosocial factors:
A systematic review and meta-analysis. Biological Psychology, 80, 265-278. doi:
10.1016/j.biopsycho.2008.10.004
Clow, A., Hucklebridge, F., Stalder, T., Evans, P., & Thorn, L. (2010). The cortisol awakening
resonse: More than a measure of HPA axis function. Neuroscience and Biobehavioral
Reviews, 35, 97-103. doi: 10.1016/j.neubiorev.2009.12.011
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. New Jersey: Lawrence
Erlbaum.
Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Applied multiple regression/correlation
analysis for the behavioral sciences. Hillsdale: Erlbaum.
Dunkley, D. M., Berg, J. L., & Zuroff, D. C. (2012). The role of perfectionism in daily selfesteem, attachment, and negative affect. Journal of Personality, 80, 633-663. doi:
10.1111/j.1467-6494.2011.00741.x
Dunkley, D. M., Blankstein, K. R., & Berg, J. L. (2012). Perfectionism dimensions and the fivefactor model of personality. European Journal of Personality, 26, 233-244. doi:
10.1002/per.829
138
Dunkley, D. M., & Kyparissis, A. (2008). What is DAS self-critical perfectionism really
measuring? Relations with the five-factor model of personality and depressive symptoms.
Personality and Individual Differences, 44, 1295-1305. doi: 10.1016/j.paid.2007.11.022
Dunkley, D. M., Lewkowski, M. D., Lee, I. A., Preacher, K. J., Zuroff, D. C., Berg, J., Foley, E.,
Myhr, G., & Westreich, R. (2016). Daily stress, coping, and negative and positive affect
in depression: Complex trigger and maintenance patterns. Manuscript submitted for
publication.
Dunkley, D. M., Mandel, T., & Ma, D. (2014). Perfectionism, neuroticism, and daily stresssadness reactivity and coping effectiveness 6 months and 3 years later. Journal of
Counseling Psychology, 61, 616-633. doi: 10.1037/cou0000036
Dunkley, D. M., Zuroff, D. C., & Blankstein, K. R. (2003). Self-critical perfectionism and daily
affect: Dispositional and situational influences on stress and coping. Journal of
Personality and Social Psychology, 84, 234-252. doi: 10.1037/0022-3514.84.1.234
Enns, M. W., & Cox, B. J. (2005). Perfectionism, stressful life events, and the 1-year outcome of
depression. Cognitive Therapy and Research, 29, 541-553. doi: 10.1007/s10608-0052414-8
Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B., Freedman, G., Murray, C. J. L., . . .
Whiteford, H. A. (2013). Burden of depressive disorders by country, sex, age, and year:
Findings from the global burden of disease study 2010. PLoS Med, 10, e1001547. doi:
10.1371/journal.pmed.1001547
First, M. B., Spitzer, R. L, Gibbon M., and Williams, J. B.W. (2002). Structured Clinical
Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition
(SCIDI/NP). New York: Biometrics Research, New York State Psychiatric Institute.
139
Flett, G. L., Hewitt, P., Blankstein, K., & Mosher, S. (1995). Perfectionism, life events, and
depressive symptoms: A test of a diathesis-stress model. Current Psychology, 14, 112137. doi: 10.1007/bf02686885
Flett, G. L., & Hewitt, P. L. (Eds.). (2002). Perfectionism: Theory, research, and treatment.
Washington, DC: American Psychological Association.
Fries, E., Dettenborn, L., & Kirschbaum, C. (2009). The cortisol awakening response (CAR):
Facts and future directions. International Journal of Psychophysiology, 72, 67-73. doi:
10.1016/j.ijpsycho.2008.03.014
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism.
Cognitive Therapy and Research, 14, 449-468. doi: 10.1007/bf01172967
Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and
self-criticism: Overview and pilot study of a group therapy approach. Clinical
Psychology and Psychotherapy, 13, 353-379. doi: 10.1002/cpp.507
Gold, P. W., Licinio, J., Wong, M. & Chrousos, G. P. (1995). Corticotropin releasing hormone in
the pathophysiology of melancholic and atypical depression and in the mechanism of
action of antidepressant drugs. Annals of the New York Academy of Sciences, 771, 716729. doi: 10.1111/j.1749-6632.1995.tb44723.x
Gunthert, K. C., Cohen, L. H., Butler, A. C., & Beck, J. S. (2005). Predictive role of daily coping
and affective reactivity in cognitive therapy outcome: Application of a daily process
design to psychotherapy research. Behavior Therapy, 36, 77-88. doi: 10.1016/s00057894(05)80056-5
140
Hardeveld, F., Spijker, J., De Graaf, R., Nolen, W. A., & Beekman, A. T. F. (2010). Prevalence
and predictors of recurence of major depressive disorder in the adult population. Acta
Psychiatrica Scandinavica, 122, 184-191. doi: 10.1111/j.1600-0447.2009.01519.x
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery &
Psychiatry, 23, 56-62. doi:10.1136/jnnp.23.1.56
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The
process and practice of mindful change (Second Edition ed.). New York, NY: Guilford
Press.
Hellhammer, D. H., Wüst, S., & Kudielka, B. M. (2009). Salivary cortisol as a biomarker in
stress research. Psychoneuroendocrinology, 34, 163-171. doi:
10.1016/j.psyneuen.2008.10.026
Hewitt, P. L., Flett, G. L., & Ediger, E. (1996). Perfectionism and depression: Longitudinal
assessment of a specific vulnerability hypothesis. Journal of Abnormal Psychology, 105,
276-280. doi: 10.1037/0021-843x.105.2.276
Hewitt, P. L., Flett, G. L., Turnbull-Donovan, W., & Mikail, S. F. (1991). The Multidimensional
Perfectionism Scale: Reliability, validity, and psychometric properties in psychiatric
samples. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3,
464-468. doi: 10.1037/1040-3590.3.3.464
Hoyt, L. T., Zeiders, K. H., Ehrlich, K. B., & Adam, E. K. (2016). Positive upshots of cortisol in
everyday life. Emotion, Advance online publication. doi: 10.1037/emo0000174
Kannan, D., & Levitt, H. M. (2013). A review of client self-criticism in psychotherapy. Journal
of Psychotherapy Integration, 23, 166-178. doi: 10.1037/a0032355
141
Katz, R., Shaw, B. F., Vallis, T. M., & Kaiser, A. S. (1995). The assessment of severity and
symptom patterns in depression. Handbook of depression (2nd ed.) (pp. 61-85). New
York, NY: Guilford Press.
Kempke, S., Luyten, P., Mayes, L. C., Van Houdenhove, B., & Claes, S. (2016). Self-critical
perfectionism predicts lower cortisol response to experimental stress in patients with
chronic fatigue syndrome. Health Psychology, 35, 296-307. doi: 10.1037/hea0000299
Kudielka, B. M., Broderick, J. E., & Kirschbaum, C. (2003). Compliance with saliva sampling
protocols: Electronic monitoring reveals invalid cortisol daytime profiles in noncompliant
subjects. Psychosomatic Medicine, 65, 313-319. doi:
10.1097/01.PSY.0000058374.50240.BF
Mandel, T., Dunkley, D. M., & Moroz, M. (2015). Self-critical perfectionism and depressive and
anxious symptoms over four years: The mediating role of daily stress reactivity. Journal
of Counseling Psychology, 62, 703-717. doi: 10.1037/cou0000101
McGirr, A., & Turecki, G. (2009). Self-critical perfectionism is associated with increases in
sympathetic indicators in a controlled laboratory stress paradigm. Psychosomatic
Medicine, 71, 588; author reply 589-590. doi: 10.1097/PSY.0b013e3181a99b64
Niles, A. N., Mesri, B., Burklund, L. J., Lieberman, M. D., & Craske, M. G. (2013). Attentional
bias and emotional reactivity as predictors and moderators of behavioral treatment for
social phobia. Behaviour Research and Therapy, 51, 669-679. doi:
10.1016/j.brat.2013.06.005
Pfohl, B., Sherman, B., Schlechte, J., & Winokur, G. (1985). Differences in plasma ACTH and
cortisol between depressed patients and normal controls. Biological Psychiatry, 20, 10551072. doi: 10.1016/0006-3223(85)90004-6
142
Powers, T. A., Zuroff, D. C., & Topciu, R. A. (2004). Covert and overt expressions of selfcriticism and perfectionism and their relation to depression. European Journal of
Personality, 18, 61-72. doi: 10.1002/per.499
Pruessner, J. C., Gaab, J., Hellhammer, D. H., Lintz, D., Schommer, N., & Kirschbaum, C.
(1997). Increasing correlations between personality traits and cortisol stress responses
obtained by data aggregation. Psychoneuroendocrinology, 22, 615-625.
doi: 10.1016/S0306-4530(97)00072-3
Pruessner, J. C., Kirschbaum, C., Meinlschmid, G., & Hellhammer, D. H. (2003). Two formulas
for computation of the area under the curve represent measures of total hormone
concentration versus time-dependent change. Psychoneuroendocrinology, 28, 916-931.
doi:10.1016/S0306-4530(02)00108-7
Richardson, C. M., Rice, K. G., & Devine, D. P. (2014). Perfectionism, emotion regulation, and
the cortisol stress response. Journal of Counseling Psychology, 61, 110-118. doi:
10.1037/a0034446
Rodrigues, S. M., LeDoux, J. E., & Sapolsky, R. M. (2009). The influence of stress hormones on
fear circuitry. Annual Review of Neuroscience, 32, 289-313. doi:
10.1146/annurev.neuro.051508.135620
Rottenberg, J., Gross, J. J., & Gotlib, I. H. (2005). Emotion context insensitivity in major
depressive disorder. Journal of Abnormal Psychology, 114, 627-639. doi: 10.1037/0021843X.114.4.627
Rottenberg, J., & Vaughan, C. (2008). Emotion expression in depression: Emerging evidence for
emotion context-insensitivity. In A. J. J. M. Vingerhoets, I. Nyklíček & J. Denollet
143
(Eds.), Emotion regulation: Conceptual and clinical issues (pp. 125-139). Boston, MA:
Springer US.
Slaney, R. B., Rice, K. G., Mobley, M., Trippi, J., & Ashby, J. S. (2001). The revised almost
perfect scale. Measurement and Evaluation in Counseling and Development, 34, 130145.
Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches, evidence,
challenges. Personality and Social Psychology Review, 10, 295-319. doi:
10.1207/s15327957pspr1004_2
Sturman, E. D., Flett, G. L., Hewitt, P. L., & Rudolph, S. G. (2009). Dimensions of
perfectionism and self-worth contingencies in depression. Journal of Rational-Emotive &
Cognitive-Behavior Therapy, 27, 213-231. doi: 10.1007/s10942-007-0079-9
Therrien, F., Drapeau, V., Lupien, S. J., Beaulieu, S., Dore, J., Tremblay, A., & Richard, D.
(2008). Awakening cortisol response in relation to psychosocial profiles and eating
behaviors. Physiology & Behavior, 93, 282-288. doi: 10.1016/j.physbeh.2007.08.019
Trajković, G., Starčević, V., Latas, M., Leštarević, M., Ille, T., Bukumirić, Z., & Marinković, J.
(2011). Reliability of the Hamilton Rating Scale for Depression: A meta-analysis over a
period of 49 years. Psychiatry Research, 189, 1-9. doi: 10.1016/j.psychres.2010.12.007
Vrshek-Schallhorn, S., Doane, L. D., Mineka, S., Zinbarg, R. E., Craske, M. G., Adam, E. K.
(2013). The cortisol awakening response predicts major depression: Predictive stability
over a 4-year follow-up and effect of depression history. Psychological Medicine, 43,
483-493. doi: 10.1017/S0033291712001213
Watson, D., & Clark, L. A. (1994). The PANAS–X: Manual for the Positive and Negative Affect
Schedule–expanded form. Iowa City: University of Iowa.
144
Weissman, A. N., & Beck, A. T. (1978). Development and validation of the Dysfunctional
Attitude Scale: A preliminary investigation. Paper presented at the 62nd Annual Meeting
of the American Educational Research Association, Toronto, Ontario, Canada.
Wichers, M., Geschwind, N., Jacobs, N., Kenis, G., Peeters, F., Derom, C., . . . van Os, J. (2009).
Transition from stress sensitivity to a depressive state: Longitudinal twin study. The
British Journal of Psychiatry, 195, 498-503. doi: 10.1192/bjp.bp.108.056853
Wichers, M., Peeters, F., Geschwind, N., Jacobs, N., Simons, C. J. P., Derom, C., . . . van Os, J.
(2010). Unveiling patterns of affective responses in daily life may improve outcome
prediction in depression: A momentary assessment study. Journal of Affective Disorders,
124, 191-195. doi: 10.1016/j.jad.2009.11.010
Wirtz, P. H., Elsenbruch, S., Emini, L., Rudisuli, K., Groessbauer, S., & Ehlert, U. (2007).
Perfectionism and the cortisol response to psychosocial stress in men. Psychosomatic
Medicine, 69, 249-255. doi: 10.1097/PSY.0b013e318042589e
Vreeburg, S. A., Hoogendijk, W. J. G., DeRijk, R. H., van Dyck, R., Smit, J. H., Zitman, F. G.,
Penninx, B. W. J. H. (2013). Salivary cortisol levels and the 2-year course of depressive
and anxiety disorders. Psychoneuroendocrinology, 38, 1494-1502. doi:
10.1016/j.psyneuen.2012.12.017
Zuroff, D. C., & Blatt, S. J. (2002). Vicissitudes of life after the short-term treatment of
depression: Roles of stress, social support, and personality. Journal of Social and Clinical
Psychology, 21, 473-496. doi: 10.1521/jscp.21.5.473.22622
Zuroff, D. C., Mongrain, M., & Santor, D. A. (2004). Conceptualizing and measuring personality
vulnerability to depression: Comment on Coyne and Whiffen (1995). Psychological
Bulletin, 130, 489-511. doi: 10.1037/0033-2909.130.3.489
145
Table 1
Intercorrelations, Means, and Standard Deviations of the Perfectionism, Stress-Sadness Reactivity, Diurnal Cortisol (AUCg), Cortisol
Awakening Response (CAR), and Depression Measures
Variables
1
2
3
4
5
6
7
8
1. T1 SC Perfectionism
-2. T1 PS Perfectionism
.65***
-3. T1 HAM-D
.27
.12
-4. T2 Stress-Sad React
.21
-.04
.36*
-5. T2 AUCg
-.02
-.06
.15
.27
-6. T2 CAR
.04
.18
.32*
.34*
.56***
-7. T2 HAM-D
.11
-.03
.51**
.70***
.30
.23
-8. T3 HAM-D
.34*
.25
.29
.48**
.10
.06
.59***
-M
.00
.00
21.19
.00
4.58
.16
15.42
13.12
SD
.83
.92
5.12
.05
4.27
.32
8.19
7.86
Note. T1 = Time 1. T2 = Time 2. T3 = Time 3. SC = Self-Critical. PS = Personal Standards. HAM-D = Hamilton Rating Scale for
Depression. Stress-Sad React = Stress-Sadness Reactivity. AUCg = Area under the curve with respect to ground. CAR = Cortisol
Awakening Response.
p < .05; ** p < .01; *** p < .001.
146
Table 2
Hierarchical Multiple Regression Analyses Predicting Time 3 Depressive Severity with StressSadness Reactivity (top) and Cortisol Awakening Response (CAR; bottom) and Perfectionism
Variables
B
SE B
95% CI
β
Adj.
2
R
ΔR2
df
ΔF
SC Perfectionism X Stress-sadness reactivity predicting T3 HAM-D
T1 HAM-D
T2 HAM-D
T2 Stress-sadness R
T1 SC Perfectionism
T1 SC X T2 Str-Sad R
.05
.49
-1.35
3.15
3.44
.22
.16
1.41
.93
1.12
[-.40, .50]
[.16, .81]
[-4.21, 1.51]
[1.26, 5.05]
[1.15, 5.73]
.04
.53
-.18
.43
.44
.05
.28
.28
.38
.50
.07
.25
.01
.11
.12
1, 37 2.84
1, 36 13.26**
1, 35
.74
1, 34 6.90*
1, 33 9.36**
SC Perfectionism X CAR predicting T3 HAM-D
T1 HAM-D
T2 HAM-D
T2 CAR
T1 SC Perfectionism
T1 SC X T2 CAR
-.09
.52
-.69
2.80
3.34
.20
.12
.89
.89
.95
[-.50, .33]
[.27, .76]
[-2.50, 1.12]
[1.00, 4.60]
[1.41, 5.28]
-.06
.54
-.09
.36
.39
.06
.32
.31
.38
.53
.08
.27
.01
.08
.14
1, 40 3.56
1, 39 16.13***
1, 38
.45
1, 37 5.52*
1, 36 12.30**
Note. T1 = Time 1. T2 = Time 2. T3 = Time 3.
SC = Self-critical. HAM-D = Hamilton Rating Scale for Depression. R = Reactivity. Str-Sad =
Stress-Sadness. CAR = Cortisol Awakening Response.
* p < .05. ** p < .01. *** p < .001.
147
Figure 1. The moderating role of Time 2 (T2) stress-sadness reactivity (SR; top) and cortisol
awakening response (CAR; bottom) on the relationship between Time 1 (T1) self-critical (SC)
perfectionism and Time 3 (T3) depressive severity. Values for SC perfectionism, SR, and CAR
are plotted using low (one standard deviation below the mean) and high (one standard deviation
above the mean) values.
18
T2 high SR
16
T2 low SR
T3Depression
14
12
10
8
6
4
2
low
hi
T1 SC Perfectionism
18
T2 high CAR
T3Depression
16
T2 low CAR
14
12
10
8
6
4
2
low
hi
T1 SC Perfectionism
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General Discussion
‘Perfection’ is a pervasive term and concept that is pursued by individuals in a wide
array of domains, ranging from athletics to academics and even to parenting. Unfortunately,
perfectionism can take the form of a chronic self-critical voice, that is preoccupied with
expectations and approval from others, and which serves to undermine the potential
achievements and psychological well-being of these very same individuals (Dunkley, et al.,
2003; Flett & Hewitt, 2002). The current thesis sought to better understand the reasons why and
the conditions under which individuals with higher SC perfectionism exhibit a broad range of
negative outcomes, with the goal of developing better treatment strategies for these individuals in
the future.
The main purpose of this thesis was to better understand the relationship between SC
perfectionism, emotional reactivity, and negative outcomes. More specifically, Article 1 aimed to
clarify the explanatory value of stress reactivity in the relationship between SC perfectionism
and depressive and anxious symptoms in a sample of community adults over a period of four
years. Using the same sample, Article 2 examined the role of interpersonal sensitivity in the
relationship between SC perfectionism and stress generation four years later. Lastly, Article 3
assessed the moderating role of stress reactivity and cortisol activity in the relationship between
SC perfectionism and depression in a sample of depressed outpatients over a one-year period.
The following sections will summarize the findings from each of these three studies and then
will go on to examine these results in terms of their greater implications for our understanding of
the relationship between personality, emotion reactivity and negative outcomes.
149
Article 1
Article 1 demonstrated that the relationship between SC perfectionism and
depressive/anxious symptoms was explained by stress reactivity. More specifically, higher SC
perfectionism predicted daily stress-sadness reactivity (i.e., greater increases in daily sadness in
response to increases in daily stress) six months and three years later, which explained why
individuals with higher SC perfectionism had more general depressive symptoms, anhedonic
depressive symptoms, and general anxious symptoms four years later, controlling for baseline
symptoms. Moreover, daily reactivity to stress with negative affect (NA) did not explain the
relationship between SC perfectionism and anhedonic symptoms. In addition, higher mean levels
of daily stress did not serve as an explanatory variable in the relationship between SC
perfectionism and any of the depressive/anxious symptom outcomes. These results highlight the
detrimental effects of stress-sadness reactivity, in contrast to stress-NA reactivity or mean levels
of stress, for individuals with higher SC perfectionism. In addition, these findings suggest that
higher SC perfectionism is a transdiagnostic risk factor for shared general depressive and general
anxious symptoms, which is consistent with Clark and Watson’s (1991) Tripartite model that
suggests that general depressive and anxious symptoms overlap significantly.
Article 2
Article 2 aimed to expand on the findings from Article 1, by examining whether different
forms of emotional reactivity may help to explain why individuals with higher SC perfectionistic
generate future stress for themselves. To elaborate, Article 2 examined whether heightened
interpersonal-sadness sensitivity (i.e., greater increases in daily sadness in response to increases
in daily negative interpersonal interactions) explained the relationship between SC perfectionism
and stress generation over a period of four years. Results showed that SC perfectionism predicted
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interpersonal-sadness sensitivity six months and three years later, which in turn predicted
dependent interpersonal stress four years later. Interpersonal-sadness sensitivity did not mediate
the relationship between SC perfectionism and dependent noninterpersonal or independent stress.
Further, responding to daily negative social interactions with NA, as opposed to sadness, did not
explain the relationship between SC perfectionism and stress generation. Moreover, mean levels
of negative social interactions also did not explain the link between higher SC perfectionism and
stress generation outcomes. These findings lend support for theoretical models that suggest a
relationship between self-criticism, disturbed relationships, and stress generation (Hewitt & Flett,
2002; Zuroff et al., 2004), but extend them by specifying interpersonal-sadness sensitivity as a
unique mediator in this relationship.
Article 3
As Articles 1 and 2 demonstrate the pervasive effects of emotional reactivity for higher
SC perfectionists in a community sample, Article 3 aimed to examine whether similar
relationships occur in a sample of depressed outpatients. Moreover, Article 3 aimed to expand on
the prior studies by incorporating a physiological measure of stress, namely diurnal cortisol
levels and the cortisol awakening response (CAR), in order to examine whether physiological
measures of stress processes corresponded with emotional reactivity levels to predict negative
outcomes for high SC perfectionists. Findings showed that patients who had higher levels of SC
perfectionism in conjunction with higher levels of daily stress-sadness reactivity (i.e., greater
increases in daily sadness in response to increases in daily stress) had higher levels of depression
maintenance at Time 3 relative to other patients, while controlling for Time 1 and 2 depression
symptoms. SC perfectionism also interacted with CAR (i.e., greater increases in salivary cortisol
upon awakening) to predict depression maintenance at Time 3, controlling for depression at
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Time 1 and Time 2. Diurnal cortisol levels did not interact with SC perfectionism to predict
depression maintenance over time. Further, high SC perfectionism in combination with lower
levels of stress-sadness reactivity/CAR was not associated with depression maintenance at Time
3. Findings from Article 3 compliment studies 1 and 2 by demonstrating that the detrimental
effects of emotional reactivity extend to clinical samples of SC perfectionists, and are mirrored
by hormonal processes such as the CAR. Interestingly, however, Article 3 also sheds light on the
potentially adaptive aspects of heightened stress reactivity/CAR. More specifically, Article 3
demonstrates that low SC perfectionism in combination with higher stress-sadness reactivity and
a larger CAR predict the lowest level of depressive symptoms one year later, controlling for the
effects of depression at Time 1 and 2.
Taken together, the above studies are a compelling demonstration of the importance and
destructiveness of high emotional reactivity and corresponding physiological measures of stress
for high SC perfectionists. More specifically, these findings suggest that emotional reactivity
contributes to a wide range of negative outcomes (i.e. depressive and anxious symptoms, stress
generation) for individuals with higher SC perfectionism.
General Implications
The current thesis brings together two separate literatures suggesting that certain
personality styles are more likely to exhibit higher emotional reactivity to stressors than others
(Dunkley, Mandel, & Ma, 2014; Suls & Martin, 2005) and that greater emotional reactivity
contributes to negative outcomes (Cohen et al., 2005; Wichers et al., 2009), with the goal of
better understanding the relationship between SC perfectionism and negative outcomes over
time.
152
The findings from Article 1 and 2 are in line with previous research demonstrating that
individuals with higher SC perfectionism do indeed exhibit higher depressive symptoms (J. R.
Cohen et al., 2013; Dunkley, Sanislow, Grilo, & McGlashan, 2006; Dunkley et al., 2009; Sherry
et al., 2014), and dependent stress (Hewitt & Flett, 2002; Shahar, Joiner, Zuroff, & Blatt, 2004),
but further add to these findings by highlighting the mechanisms that explain this relationship.
Moreover, the current findings are in line with previous research noting a positive link between
perfectionism and maladaptive emotion regulation strategies and a negative association between
perfectionism and adaptive emotion regulation strategies (Rudolph, Flett, & Hewitt, 2007). The
current findings from Articles 1 and 2 are also consistent with important research demonstrating
that emotion dysregulation explained the relationship between maladaptive perfectionism and
psychological distress (Aldea & Rice, 2006), but extend these findings by applying a more
rigorous measure of emotional reactivity that utilized 14 days of daily diaries to capture the
within-person relationship between daily stressors and mood (Cohen et al., 2005). Articles 1 and
2 also extend findings from Aldea and Rice (2006) by testing these relations over a period of
four years, which allows for significant insight into the impact of emotional reactivity over the
longer term.
Article 3 demonstrates that higher SC perfectionism in conjunction with emotional
reactivity as well as certain forms of cortisol activity predict depression maintenance in a sample
of depressed outpatients undergoing treatment over time. These findings add to the small but
growing body of literature on the relationship between SC perfectionism, emotion regulation,
and cortisol activity (Richardson et al., 2014), by emphasizing the importance of both stresssadness reactivity as well as elevated levels of CAR in the relationship between SC
perfectionism and depression. Our results also suggest that higher SC perfectionists are
153
especially vulnerable to depression when experiencing a higher CAR as opposed to higher levels
of total daily cortisol, which is in line with previous research stating that the CAR provides
unique information in relation to psychological processes, even when other cortisol measures fail
to detect a link to psychological factors (Dienes, Hazel, & Hammen, 2012; Vrshek-Schallhorn,
2013). Interestingly, however, these findings also suggest that reducing the level of stresssadness reactivity or CAR may not necessarily be the most beneficial for this group, as
individuals with higher SC perfectionism and lower stress-sadness reactivity or a lower CAR still
maintain moderate levels of depressive symptoms as well. In addition, results suggest that lower
levels of SC perfectionism in conjunction with higher levels of stress-sadness reactivity/CAR
leads to the lowest level of depressive maintenance. Thus, these results suggest that for high SC
perfectionistic patients, it may be beneficial to target their SC perfectionistic tendencies while
having them maintain a somewhat moderate level of stress-sadness reactivity or CAR, as
opposed to targeting their higher emotional reactivity or heightened CAR.
The findings from these three articles may be partially explained by the fact that
individuals with higher SC perfectionism are known to interpret stressors as representing an
inability to retain control, which they are especially vulnerable to because a loss of control may
be perceived as a potential failure of the self in the eyes of both themselves and others (Flett &
Hewitt, 2002). The potential for perceived failure may then lead high SC perfectionists to
respond to stress with a helplessness orientation, which then may influence negative cognitive
interpretations that further promote problematic outcomes (Beck et al., 1979; Dunkley et al.,
2003; Flett & Hewitt, 2002). By extension, given that the CAR may be associated with helping
to prepare an individual for upcoming daily demands (Adam et al., 2010; Chida & Steptoe, 2009;
Fries, Dettenborn, & Kirschbaum, 2009), the presence of a high CAR for individuals with high
154
SC perfectionism may signal that they anticipate being unable to adequately manage upcoming
demands, which leads them to respond with a helplessness orientation and avoidance, which may
contribute to greater depression over time (e.g., Dunkley et al., 2003; Dunkley, Mandel, et al.,
2014).
Though results from all three articles lend support for Beck and colleagues’ theory
(1979), which states that responding negatively to an event predicts the maintenance or onset of
negative outcomes, results from Article 3 also offer support for the theory that high levels of
emotional reactivity may be protective under certain circumstances (Rottenberg, Gross, &
Gotlib, 2005). Higher levels of emotional reactivity may be adaptive for individuals with low
levels of SC perfectionism, potentially because they are less likely to interpret the presence of
stress as representing a potential failure of the self. Furthermore, low SC perfectionists may
exhibit important strengths that allow them to better distance themselves from and accept their
appraisal-emotion responses, which allows them to respond to their emotional reactions with a
more kind and compassionate stance. This adaptive stance may translate their appraisal-emotion
responses into a motivating force that helps them to engage, as opposed to avoid, their emotional
reactions, which may lead to fewer depressive symptoms over time (Gilbert & Procter, 2006;
Hayes, Strosahl, & Wilson, 2012; Niles, Mesri, Burklund, Lieberman, & Craske, 2013). In
addition, this heightened reactivity may serve to communicate important information about their
current emotions and may provide them with social benefits by eliciting a greater degree of
social engagement from others (Rottenberg et al., 2005; Rottenberg & Vaughan, 2008).
Similarly, a heightened CAR may be protective for low SC perfectionists because it may provide
them with an important boost in energy, which may signal an ability to prepare and cope with the
155
day’s upcoming demands (Adam et al., 2010; Chida & Steptoe, 2009; Fries, et al., 2009; Hoyt et
al., 2016).
Clinical Implications
Findings from the three studies featured in this thesis have significant clinical
implications. Article 1 suggests that in order to lessen the likelihood that those with higher levels
of SC perfectionism exhibit increases in depressive and anxious symptoms over time, it is
important for them to better regulate the degree of sadness that they experience in the face of
daily stressors. Article 2 demonstrates that higher SC perfectionists generate interpersonal stress
from themselves because they are more sensitive to negative interpersonal exchanges. These
results are critical as they demonstrate the importance of better managing emotional reactivity in
order to minimize the likelihood of negative outcomes over time. Article 3 highlights that higher
stress-sadness reactivity and a greater CAR are important factors that exacerbate the impact of
SC perfectionism on depression one year later.
Results from Articles 1 and 2 also show that simply aiming to reduce stress
levels/negative social interactions overall has less of an impact on higher SC perfectionists’ wellbeing than targeting their emotional response to stress/negative social interactions specifically.
Clinically speaking, this finding may provide good news for highly SC individuals, as it may be
easier to learn to better react to stressors than to minimize stress levels overall. This is because
emotional reactivity lies within the individual and is, at least to some degree, within their control
(Gross, 2001; Gross & John, 2003), whereas we may have less control over the presence of
certain stressors/negative social interactions (Lazarus & Folkman, 1984). As a result, one can
imagine that individuals with higher SC perfectionism may fair better by learning to respond
156
differently to their daily stressors than working towards minimizing overall stress from their
daily life.
In addition, results from Articles 1 and 2 suggest that individuals with higher SC
perfectionism, who respond to stress with sadness, as opposed to broader emotions such as
negative affect, are most at risk for experiencing later psychological difficulties. This
discrepancy makes sense given that emotions have different purposes, and is in line with
previous research suggesting that responding to stress with sadness may lead an individual to
disengage more readily, leading to more negative consequences over time (Watson, Clark, &
Stasik, 2011; see Carver & Harmon-Jones, 2009; Lindebaum & Jordan, 2014). Furthermore,
sadness has been characterized by attributions of external as opposed to internal control (Lerner
& Keltner, 2000). Given that SC perfectionists are especially vulnerable to threats that indicate a
possible loss of control, the experience of sadness may be especially problematic for them (Blatt,
1995; Flett & Hewitt, 2002). Thus, it seems that future interventions for highly SC perfectionistic
individuals should target enhanced emotion regulation skills that focus on reducing their degree
of sadness in response to stress but that also help the highly SC individual to respond to stressors
in a more varied, and therefore potentially adaptive, manner.
There are several possible avenues that exist which may be helpful in learning to decrease
emotional reactivity. Firstly, emotional reactivity may be better managed by up regulating
positive emotions and down regulating negative emotions (specifically sadness) (DeSteno,
Gross, & Kubzansky, 2013). In order to enhance levels of positive emotions and diminish levels
of negative mood when confronted with a stressor, higher SC perfectionistic individuals may
benefit from reappraisal, which involves regulating emotional reactions by reflecting on the more
desirable aspects of a situation as opposed to the more deleterious aspects (Gross, 2001). Indeed,
157
research has shown that higher SC perfectionists have less sadness on days where they positively
reinterpret a stressor (Dunkley, Mandel, et al. 2014). Another strategy that may be useful for
individuals with higher SC perfectionism is problem-focused coping, given that these individuals
have been shown to exhibit less sadness and more positive affect on days where they employ
problem-focused coping in the face of their daily stressors (Dunkley, Mandel, et al. 2014).
Secondly, there exist various therapies that aim to provide individuals with more helpful
emotion regulation skills. Dialectical behavioral therapy (DBT; Linehan, 1993) is a therapy that
was originally developed to help treat borderline personality disorder; however, many elements
of DBT are now widely used to help individuals better react to emotions in general. DBT for
emotion regulation includes helping individuals to better identify and describe emotions, such
that they can becoming mindful of their emotional reactions in order to learn to respond
differently in the future (McKay, Wood, & Brantley, 2007). Cognitive techniques have also
shown some promise in regards to improved emotion reactivity, as they promote cognitively
restructuring how one interprets increases in stress (Niles et al., 2013). Acceptance and
mindfulness-based strategies have also been shown to be effective at helping individuals to
distance themselves from and better accept their emotions, which allows them to react more
intentionally in the future (Hayes et al., 2012; Niles et al., 2013).
Clinical implications for Article 3 are somewhat different from those of Article 1 and 2,
as results suggest that low SC perfectionism in conjunction with high emotional reactivity or
CAR predicts the lowest level of depression following treatment. Thus, targeting the SC
perfectionistic tendencies may be the most helpful for high SC perfectionistic patients as
opposed to directly targeting their emotional or physiological responses. SC perfectionistic
attitudes can be targeted by working to increase levels of self-compassion, which may involve
158
learning to genuinely care for oneself, become sensitive, non-judgmental and tolerant of our
distress, and respond with self-warmth and caring in the face of difficulty. This form of
treatment, also referred to as compassionate mind training (CMT), has been shown to be
effective for individuals with high levels of self-criticism (Gilbert & Procter, 2006).
Lastly, clinical implications that stem from all three articles regarding the role of the
therapist may be of interest as well. Positive therapist qualities such as a Rogerian orientation,
which involves conveying genuine positive regard and empathy towards clients, and which
typically has a positive impact on treatment outcomes (Zuroff, Kelly, Leybman, Blatt, &
Wampold, 2010), appears to be less helpful for individuals with higher SC perfectionism (Zuroff,
Shahar, Blatt, Kelly, & Leybman, 2016). These findings are theorized to be due to the fact that
SC perfectionists may perceive and react more strongly to even slight breaks in Rogerian
attitude, which may suggest that SC perfectionists may benefit from a therapist who is prepared
to readily cope with frequent therapeutic ruptures and with whom they can build a strong
therapeutic relationship (Kelly & Zuroff, 2014; Shahar, 2013; Zuroff et al., 2016). In addition, it
is possible that higher SC perfectionism in conjunction with higher levels of emotional and
physiological activation lead to the highest level of depressive symptoms in Article 3 because
high SC perfectionists tend to interpret even slight emotional or physiological stressors as
threatening their need for control (Hewitt & Flett, 1993). Thus, in addition to targeting SC
perfectionism tendencies directly in clinical samples, therapy should focus on helping high SC
perfectionists reinterpret their understanding of their emotional or physiological response to
stress so that it does not trigger a later cascade of negative outcomes (Beck et al., 1979; Dunkley
et al., 2003).
159
Limitations and future directions
The current thesis had several strengths, including the use of both community as well as
clinical samples, the use of longitudinal designs, the daily diary methodology, the life stress
interview and inclusion of cortisol measures. However, there remain several noteworthy
limitations to this research. In Article 1, measures were based on self-report data that may be
limited by subjective biases. Future research would benefit from including additional alternative
measures of emotional reactivity as well as depressive and anxious symptoms in order to
decrease the likelihood of distorted perceptions, memory biases, and social desirability.
Furthermore, in all three studies, participants used paper and pencil daily diaries to report their
most bothersome event of the day and their corresponding mood at the end of the day, and thus
recollection bias may have interfered with their reporting. Future research should incorporate
electronic diaries that prompt participants to enter their appraisals and corresponding mood
multiple times throughout the day in order to minimize recollection biases and better capture
potential changes in emotional reactivity that occur throughout the day (Shiffman, Stone, &
Hufford, 2008). In addition, stronger conclusions could have been drawn in all three studies had
each predictor, mediator/moderator, and outcome variable been measured at each time point.
Future research could benefit from incorporating repeated measures at each time point to also
help clarify the temporal ordering of our findings (see D. A. Cole & Maxwell, 2003).
Another question raised by the present thesis is whether emotional reactivity processes
behave differently in non-clinical versus clinical populations. A possible future research
direction may involve testing emotional reactivity in a sample that consists of both non-clinical
and clinical SC individuals, and evaluating what factors may help to explain any potential
differences. Furthermore, an important avenue for future research may include identifying the
160
processes that help to explain the link between emotional reactivity and psychosocial
maladjustment outcomes in higher SC perfectionists. Theory and research suggest that possible
mechanisms of interest may include coping style (Dunkley, Mandel, et al., 2014), cognitive
orientation (Beck et al., 1979), and attachment difficulties (Aldea & Rice, 2006; Cooper, Shaver,
& Collins, 1998; Kobak & Sceery, 1988). Identification of these mechanisms may further help to
clarify the relationship between SC perfectionism and negative outcomes, leading to increasingly
tailored interventions for high SC perfectionists.
Importantly, though the current thesis demonstrated that emotion reactivity plays a role in
the relationship between SC perfectionism and negative outcomes, these studies did not examine
whether interventions targeted at improving emotion reactivity would help to prevent negative
outcomes for SC perfectionists. Given that previous research has found that individuals with
higher levels of SC perfectionism benefit less from therapy (Blatt & Zuroff, 2005; Kannan &
Levitt, 2013), future research is warranted in order to investigate whether interventions that
target emotional reactivity do indeed help individuals with higher SC perfectionism to better
benefit from therapy. More specifically, future research should assess whether reducing levels of
emotional reactivity would have an effect on the relationship between SC perfectionism and
subclinical distress symptoms, interpersonal stress generation, or clinical depression over time.
Conclusion
The present work contributes to our understanding of the processes that link personality
vulnerability to distress over time. This thesis investigated important factors that help to explain
the relationship between facets of perfectionism and negative outcomes. Results from the three
articles help to elucidate the processes through which SC perfectionism relates to a host of
psychosocial difficulties over time, both in community as well as clinical samples. More
161
specifically, the present thesis demonstrates the relevance of emotional reactivity as well as the
CAR as important factors in the relationship between SC perfectionism and negative outcomes
over time. The current thesis highlights important avenues for future research and interventions
targeted at helping SC perfectionistic individuals exhibit fewer psychological difficulties over
time.
162
General References
Adam, E. K., Doane, L. D., Zinbarg, R. E., Mineka, S., Craske, M. G., & Griffith, J. W. (2010).
Prospective prediction of major depressive disorder from cortisol awakening responses in
adolescence. Psychoneuroendocrinology, 35, 921-931. doi:
10.1016/j.psyneuen.2009.12.007
Aldea, M. A., & Rice, K. G. (2006). The role of emotional dysregulation in perfectionism and
psychological distress. Journal of Counseling Psychology, 53, 498-510. doi:
10.1037/0022-0167.53.4.498
Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York:
Guilford.
Antony, M. M., Purdon, C. L., Huta, V., & Swinson, R. P. (1998). Dimensions of perfectionism
across the anxiety disorders. Behaviour Research and Therapy, 36, 1143-1154. doi:
10.1016/S0005-7967(98)00083-7
Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S.,
& Simonich, H. (2007). Perfectionism and eating disorders: Current status and future
directions. Clinical Psychology Review, 27, 384-405. doi: 10.1016/j.cpr.2006.12.005
Barrow, J. C., & Moore, C. A. (1983). Group interventions with perfectionistic thinking. The
Personnel and Guidance Journal, 61, 612-615. doi: 10.1111/j.2164-4918.1983.tb00008.x
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford Press.
Békés, V., Dunkley, D. M., Taylor, G., Zuroff, D. C., Lewkowski, M., Elizabeth Foley, J., . . .
Westreich, R. (2015). Chronic stress and attenuated improvement in depression over 1
163
year: The moderating role of perfectionism. Behavior Therapy, 46, 478-492. doi:
10.1016/j.beth.2015.02.003
Blatt, S. J. (1995). The destructiveness of perfectionism: Implications for the treatment of
depression. American Psychologist, 50, 1003-1020. doi: 10.1037/0003-066x.50.12.1003
Blatt, S. J., D'Afflitti, J. P., & Quinlan, D. M. (1976). Experiences of depression in normal young
adults. Journal of Abnormal Psychology, 85, 383-389. doi: 10.1037/0021-843X.85.4.383
Blatt, S. J., & Zuroff, D. C. (2005). Empirical evaluation of the assumptions in identifying
evidence based treatments in mental health. Clinical Psychology Review, 25, 459-486.
doi: 10.1016/j.cpr.2005.03.001
Burns, D. D. (1980). The perfectionist's script for self-defeat. Psychology Today, 34-52.
Carnegie, R., Araya, R., Ben-Shlomo, Y., Glover, V., O’Connor, T. G., O’Donnell, K. J., &
Pearson, R., Lewis, G. (2014). Cortisol awakening response and subsequent depression:
Prospective longitudinal study. The British Journal of Psychiatry, 204, 137-143. doi:
10.1192/bjp.bp.113.126250
Carver, C. S., & Harmon-Jones, E. (2009). Anger is an approach-related affect: Evidence and
implications. Psychological Bulletin, 135, 183-204. doi: 10.1037/a0013965
Chang, E. C. (2000). Perfectionism as a predictor of positive and negative psychological
outcomes: Examining a mediation model in younger and older adults. Journal of
Counseling Psychology, 47, 18-26. doi: 10.1037/0022-0167.47.1.18
Chang, E. C., & Rand, K. L. (2000). Perfectionism as a predictor of subsequent adjustment:
Evidence for a specific diathesis-stress mechanism among college students. Journal of
Counseling Psychology, 47, 129-137. doi: 10.1037/0022-0167.47.1.129
164
Charles, S. T., Piazza, J. R., Mogle, J., Sliwinski, M. J., & Almeida, D. M. (2013). The wear and
tear of daily stressors on mental health. Psychological Science, 24, 733-741. doi:
10.1177/0956797612462222
Chida, Y., & Steptoe, A. (2009). Cortisol awakening response and psychosocial factors: A
systematic review and meta-analysis. Biological Psychology, 80, 265-278. doi:
10.1016/j.biopsycho.2008.10.004
Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric
evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316336. doi: 10.1037/0021-843X.100.3.316
Clow, A., Hucklebridge, F., Stalder, T., Evans, P., & Thorn, L. (2010). The cortisol awakening
response: More than a measure of HPA axis function. Neuroscience & Biobehavioral
Reviews, 35, 97-103. doi: 10.1016/j.neubiorev.2009.12.011
Cohen, J. R., Young, J. F., Hankin, B. L., Yao, S., Zhu, X. Z., & Abela, J. R. (2013). Personality
predispositions in Chinese adolescents: The relation between self-criticism, dependency,
and prosepctive internalizing symptoms. Journal of Social and Clinical Psychology, 32,
596-618. doi: 10.1521/jscp.2013.32.6.596
Cohen, L. H., Gunthert, K. C., Butler, A. C., O'Neill, S. C., & Tolpin, L. H. (2005). Daily
affective reactivity as a prospective predictor of depressive symptoms. Journal of
Personality, 73, 1687-1714. doi: 10.1111/j.0022-3506.2005.00363.x
Cole, D. A., Martin, N. C., Sterba, S. K., Sinclair-McBride, K., Roeder, K. M., Zelkowitz, R., &
Bilsky, S. A. (2014). Peer victimization (and harsh parenting) as developmental
correlates of cognitive reactivity, a diathesis for depression. Journal of Abnormal
Psychology, 123, 336-349. doi:10.1037/a0036489
165
Cole, D. A., & Maxwell, S. E. (2003). Testing mediational models with longitudinal data:
Questions and tips in the use of structural equation modeling. Journal of Abnormal
Psychology, 112, 558-577. doi: 10.1037/0021-843x.112.4.558
Cooper, M. L., Shaver, P. R., & Collins, N. L. (1998). Attachment styles, emotion regulation,
and adjustment in adolescence. Journal of Personality and Social Psychology, 74, 13801397. doi: 10.1037/0022-3514.74.5.1380
DeSteno, D., Gross, J. J., & Kubzansky, L. (2013). Affective science and health: The importance
of emotion and emotion regulation. Health Psychology, 32, 474-486. doi:
10.1037/a0030259
Dienes, K. A., Hazel, N. A., & Hammen, C. L. (2012). Cortisol secretion in depressed, and atrisk adults. Psychoneuroendocrinology, 38, 927-940. doi:
10.1016/j.psyneuen.2012.09.019
Dunkley, D. M., & Blankstein, K. R. (2000). Self-critical perfectionism, coping, hassles, and
current distress: A structural equation modeling approach. Cognitive Therapy and
Research, 24, 713-730. doi: 10.1023/a:1005543529245
Dunkley, D. M., Blankstein, K. R., Halsall, J., Williams, M., & Winkworth, G. (2000). The
relation between perfectionism and distress: Hassles, coping, and perceived social
support as mediators and moderators. Journal of Counseling Psychology, 47, 437-453.
doi: 10.1037/0022-0167.47.4.437
Dunkley, D. M., Blankstein, K. R., Masheb, R. M., & Grilo, C. M. (2006). Personal standards
and evaluative concerns dimensions of "clinical" perfectionism: A reply to Shafran et al.
(2002, 2003) and Hewitt et al. (2003). Behavioural Research and Therapy, 44, 63-84.
doi: 10.1016/j.brat.2004.12.004
166
Dunkley, D. M., Ma, D., Lee, I. A., Preacher, K. J., & Zuroff, D. C. (2014). Advancing complex
explanatory conceptualizations of daily negative and positive affect: Trigger and
maintenance coping action patterns. Journal of Counseling Psychology, 61, 93-109. doi:
10.1037/a0034673
Dunkley, D. M., Mandel, T., & Ma, D. (2014). Perfectionism, neuroticism, and daily stress
reactivity and coping effectiveness 6 months and 3 years later. Journal of Counseling
Psychology, 61, 616-633. doi: 10.1037/cou0000036
Dunkley, D. M., Sanislow, C. A., Grilo, C. M., & McGlashan, T. H. (2006). Perfectionism and
depressive symptoms 3 years later: Negative social interactions, avoidant coping, and
perceived social support as mediators. Comprehensive Psychiatry, 47, 106-115. doi:
10.1016/j.comppsych.2005.06.003
Dunkley, D. M., Sanislow, C. A., Grilo, C. M., & McGlashan, T. H. (2009). Self-criticism versus
neuroticism in predicting depression and psychosocial impairment for 4 years in a clinical
sample. Comprehensive Psychiatry, 50, 335-346. doi: 10.1016/j.comppsych.2008.09.004
Dunkley, D. M., Zuroff, D. C., & Blankstein, K. R. (2003). Self-critical perfectionism and daily
affect: Dispositional and situational influences on stress and coping. Journal of
Personality and Social Psychology, 84, 234-252. doi: 10.1037//0022-3514.84.1.234
Dunkley, D. M., Zuroff, D. C., & Blankstein, K. R. (2006). Specific perfectionism components
versus self-criticism in predicting maladjustment. Personality and Individual Differences,
40, 665-676. doi: 10.1016/j.paid.2005.08.008
Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A
clinical review. Clinical Psychology Review, 31, 203-212. doi: 10.1016/j.cpr.2010.04.009
167
Enns, M. W., & Cox, B. J. (1999). Perfectionism and depression symptom severity in major
depressive disorder. Behaviour Research and Therapy, 37, 783-794. doi: 10.1016/S00057967(98)00188-0
Enns, M. W., & Cox, B. J. (2005). Perfectionism, stressful life events, and the 1-year outcome of
depression. Cognitive Therapy and Research, 29, 541-553. doi: 10.1007/s10608-0052414-8
Enns, M. W., Cox, B. J., & Clara, I. P. (2005). Perfectionism and neuroticism: A longitudinal
study of specific vulnerability and diathesis-stress models. Cognitive Therapy and
Research, 29, 463-478. doi: 10.1007/s10608-005-2843-04
Flett, G. L., Hewitt, P., Blankstein, K., & Mosher, S. (1995). Perfectionism, life events, and
depressive symptoms: A test of a diathesis-stress model. Current Psychology, 14, 112137. doi: 10.1007/bf02686885
Flett, G. L., & Hewitt, P. L. (2002). Perfectionism and maladjustment: An overview of
theoretical, definitional, and treatment issues. In G. L. Flett & P. L. Hewitt (Eds.),
Perfectionism: Theory, research, and treatment (pp. 5-31): Washington, DC: American
Psychological Association.
Flett, G. L., Hewitt, P. L., Oliver, J. M., & Macdonald, S. (2002). Perfectionism in children and
their parents: A developmental analysis. In G. L. Flett & P. L. Hewitt (Eds.),
Perfectionism (pp. 89-132). Washington, DC: American Psychological Association.
Fries, E., Dettenborn, L., & Kirschbaum, C. (2009). The cortisol awakening response (CAR):
Facts and future directions. International Journal of Psychophysiology, 72, 67-73. doi:
10.1016/j.ijpsycho.2008.03.014
168
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism.
Cognitive Therapy and Research, 14, 449-468. doi: 10.1007/bf01172967
Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and
self-criticism: Overview and pilot study of a group therapy approach. Clinical
Psychology & Psychotherapy, 13, 353-379. doi: 10.1002/cpp.507
Gold, P. W., Licinio, J., Wong, M., & Chrousos, G. P. (1995). Corticotropin releasing hormone
in the pathophysiology of melancholic and atypical depression and in the mechanism of
action of antidepressant drugs. Annals of the New York Academy of Sciences, 771, 716729. doi: 10.1111/j.1749-6632.1995.tb44723.x
Gross, J. J. (2001). Emotion regulation in adulthood: Timing is everything. Current Directions in
Psychological Science, 10, 214-219. doi: 10.1111/1467-8721.00152
Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes:
Implications for affect, relationships, and well-being. Journal of Personality and Social
Psychology, 85, 348-362. doi: 10.1037/0022-3514.85.2.348
Gunthert, K. C., Cohen, L. H., Butler, A. C., & Beck, J. S. (2005). Predictive role of daily coping
and affective reactivity in cognitive therapy outcome: Application of a daily process
design to psychotherapy research. Behavior Therapy, 36, 77-88. doi: 10.1016/s00057894(05)80056-5
Hamachek, D. E. (1978). Psychodynamics of normal and neurotic perfectionism. Psychology: A
Journal of Human Behavior, 15, 27-33.
Hammen, C. (1991). Generation of stress in the course of unipolar depression. Journal of
Abnormal Psychology, 100, 555-561. doi: 10.1037/0021-843X.100.4.555
169
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The
process and practice of mindful change (Second Edition ed.). New York, NY: Guilford
Press.
Hellhammer, D. H., Wüst, S., & Kudielka, B. M. (2009). Salivary cortisol as a biomarker in
stress research. Psychoneuroendocrinology, 34, 163-171. doi:
10.1016/j.psyneuen.2008.10.026
Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts:
Conceptualization, assessment, and association with psychopathology. Journal of
Personality and Social Psychology, 60, 456-470. doi: 10.1037/0022-3514.60.3.456
Hewitt, P. L., & Flett, G. L. (1993). Dimensions of perfectionism, daily stress, and depression: A
test of the specific vulnerability hypothesis. Journal of Abnormal Psychology, 102, 5865. doi: 10.1037/0021-843x.102.1.58
Hewitt, P. L., & Flett, G. L. (2002). Perfectionism and stress processes in psychopathology. In G.
L. Flett & P. L. Hewitt (Eds.), Perfectionism: Theory, research, and treatment (pp. 255284): Washington, DC: American Psychological Association.
Hoyt, L. T., Zeiders, K. H., Enrilich, K. B., & Adam, E. K. (2016). Positive upshots of cortisol in
everyday life. Emotion, Advance online publication. doi: 10.1037/emo0000174
Juster, H. R., Heimberg, R. G., Frost, R. O., Holt, C. S., Mattia, J. I., & Faccenda, K. (1996).
Social phobia and perfectionism. Personality and Individual Differences, 21, 403-410.
doi: 10.1016/0191-8869(96)00075-X
Kannan, D., & Levitt, H. M. (2013). A review of client self-criticism in psychotherapy. Journal
of Psychotherapy Integration, 23, 166-178. doi: 10.1037/a0032355
170
Kelly, A. C., & Zuroff, D. C. (2014). Perfectionism. In E. Gordon & R. Heimberg (Eds.),
Translating research into practice: A desk reference for practiciing mental health
professionals (pp. 233-236). New York, NY: Springer.
Kempke, S., Luyten, P., Mayes, L. C., Van Houdenhove, B., & Claes, S. (2015). Self-critical
perfectionism predicts lower cortisol response to experimental stress in patients with
chronic fatigue syndrome. Health Psychology, Advance online publication. doi:
10.1037/hea0000299
Kirschbaum, C., Pirke, K. M., & Hellhammer, D. H. (1993). The 'Trier Social Stress Test'--a tool
for investigating psychobiological stress responses in a laboratory setting.
Neuropsychobiology, 28, 76-81. doi: 119004
Kobak, R. R., & Sceery, A. (1988). Attachment in late adolescence: Working models, affect
regulation, and representations of self and others. Child Development, 59, 135-146. doi:
10.2307/1130395
Kudielka, B. M., & Wüst, S. (2010). Human models in acute and chronic stress: Assessing
determinants of individual hypothalamus–pituitary–adrenal axis activity and reactivity.
Stress, 13, 1-14. doi: 10.3109/10253890902874913
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Lerner, J. S., & Keltner, D. (2000). Beyond valence: Toward a model of emotion-specific
influences on judgement and choice. Cognition & Emotion, 14, 473-493. doi:
10.1080/026999300402763
Lindebaum, D., & Jordan, P. J. (2014). When it can be good to feel bad, and bad to feel good –
Exploring asymmetries in workplace emotional outcomes. Human Relations, 66, 1-14.
doi: 10.1177/0018726712474403
171
Linehan, M. M. (1993). Cognitive-Behavioral Treatment for Borderling Personality Disorder.
New York, NY: Guildford.
Luyten, P., Kempke, S., Van Wambeke, P., Claes, S., Blatt, S. J., & Van Houdenhove, B. (2011).
Self-critical perfectionism, stress generation, and stress sensitivity in patients with
chronic fatigue syndrome: Relationship with severity of depression. Psychiatry, 74, 2130. doi: 10.1521/psyc.2011.74.1.21
McCrae, R. R., & Costa, P. T., Jr. (2008). The Five-Factor Theory of personality. In R. W. R.
O.P. John, and L.A. Pervin (Ed.), Handbook of personality: Theory and research (3rd
ed.). New York, NY: Guilford.
McGirr, A., & Turecki, G. (2009). Self-critical perfectionism is associated with increases in
sympathetic indicators in a controlled laboratory stress paradigm. Psychosomatic
Medicine, 71, 588; author reply 589-590. doi: 10.1097/PSY.0b013e3181a99b64
McGrath, D. S., Sherry, S. B., Stewart, S. H., Mushquash, A. R., Allen, S. L., Nealis, L. J., &
Sherry, D. L. (2012). Reciprocal relations between self-critical perfectionism and
depressive symptoms: Evidence from a short-term, four-wave longitudinal study.
Canadian Journal of Behavioural Science / Revue canadienne des sciences du
comportement, 44, 169-181. doi: 10.1037/a0027764
McKay, M., Wood, J., & Brantley, J. (2007). The Dialectical Behavior Therapy skills workbook:
Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion
regulation, and distress tolerance. Oakland, CA: New Harbinger Publications.
Molnar, D. S., Sadava, S. W., Flett, G. L., & Colautti, J. (2012). Perfectionism and health: A
mediational analysis of the roles of stress, social support and health-related behaviours.
Psychology & Health, 27, 846-864. doi: 10.1080/08870446.2011.630466
172
Nater, U. M., & Rohleder, N. (2009). Salivary alpha-amylase as a non-invasive biomarker for the
sympathetic nervous system: Current state of research. Psychoneuroendocrinology, 34,
486-496. doi: 10.1016/j.psyneuen.2009.01.014
Niles, A. N., Mesri, B., Burklund, L. J., Lieberman, M. D., & Craske, M. G. (2013). Attentional
bias and emotional reactivity as predictors and moderators of behavioral treatment for
social phobia. Behaviour Research and Therapy, 51, 669-679. doi:
10.1016/j.brat.2013.06.005
O'Neill, S. C., Cohen, L. H., Tolpin, L. H., & Gunthert, K. C. (2004). Affective reactivity to
daily interpersonal stressors as a prospective predictor of depressive symptoms. Journal
of Social and Clinical Psychology, 23, 172-194. doi: 10.1521/jscp.23.2.172.31015
Pfohl, B., Sherman, B., Schlechte, J., & Winokur, G. (1985). Differences in plasma ACTH and
cortisol between depressed patients and normal controls. Biological Psychiatry, 20, 10551072. doi: 10.1016/0006-3223(85)90004-6
Piazza, J. R., Charles, S. T., Sliwinski, M. J., Mogle, J., & Almeida, D. M. (2013). Affective
reactivity to daily stressors and long-term risk of reporting a chronic physical health
condition. Annals of Behavioral Medicine, 45, 110-120. doi: 10.1007/s12160-012-9423-0
Powers, T. A., Zuroff, D. C., & Topciu, R. A. (2004). Covert and overt expressions of selfcriticism and perfectionism and their relation to depression. European Journal of
Personality, 18, 61-72. doi: 10.1002/per.499
Pruessner, J. C., Gaab, J., Hellhammer, D. H., Lintz, D., Schommer, N., & Kirschbaum, C.
(1997). Increasing correlations between personality traits and cortisol stress responses
obtained by data aggregation. Psychoneuroendocrinology, 22, 615-625.
doi:10.1016/S0306-4530(97)00072-3
173
Pruessner, J. C., Kirschbaum, C., Meinlschmid, G., & Hellhammer, D. H. (2003). Two formulas
for computation of the area under the curve represent measures of total hormone
concentration versus time-dependent change. Psychoneuroendocrinology, 28, 916-931.
doi: 10.1016/S0306-4530(02)00108-7
Rice, K. G., Leever, B. A., Christopher, J., & Porter, J. D. (2006). Perfectionism, stress, and
social (dis)connection: A short-term study of hopelessness, depression, and academic
adjustment among honors students. Journal of Counseling Psychology, 53, 524-534. doi:
10.1037/0022-0167.53.4.524
Richardson, C. M., Rice, K. G., & Devine, D. P. (2014). Perfectionism, emotion regulation, and
the cortisol stress response. Journal of Counseling Psychology, 61, 110-118. doi:
10.1037/a0034446
Rodrigues, S. M., LeDoux, J. E., & Sapolsky, R. M. (2009). The influence of stress hormones on
fear circuitry. Annual Review of Neuroscience, 32, 289-313. doi:
10.1146/annurev.neuro.051508.135620
Rottenberg, J., Gross, J. J., & Gotlib, I. H. (2005). Emotion context insensitivity in major
depressive disorder. Journal of Abnormal Psychology, 114, 627-639. doi: 10.1037/0021843x.114.4.627
Rottenberg, J., & Vaughan, C. (2008). Emotion expression in depression: Emerging evidence for
emotion context-insensitivity. In A. J. J. M. Vingerhoets, I. Nyklíček & J. Denollet
(Eds.), Emotion regulation: Conceptual and clinical issues (pp. 125-139). Boston, MA:
Springer US.
174
Rudolph, S. G., Flett, G. L., & Hewitt, P. L. (2007). Perfectionism and deficits in cognitive
emotion regulation. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 25,
343-357. doi: 10.1007/s10942-007-0056-3
Saboonchi, F., Lundh, L. G., & Ost, L. G. (1999). Perfectionism and self-consciousness in social
phobia and panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 799808. doi: 10.1016/S0005-7967(98)00183-1
Shahar, G. (2013). An integrative psychotherapist’s account of his focus when treating selfcritical patients. Psychotherapy, 50, 322-325. doi: 10.1037/a0032033
Shahar, G., Joiner, T. E., Jr., Zuroff, D. C., & Blatt, S. J. (2004). Personality, interpersonal
behavior, and depression: Co-existence of stress-specific moderating and mediating
effects. Personality and Individual Differences, 36, 1583-1596. doi:
10.1016/j.paid.2003.06.006
Sherry, S. B., Nealis, L. J., Macneil, M. A., Stewart, S. H., Sherry, D. L., & Smith, M. M.
(2013). Informant reports add incrementally to the understanding of the perfectionism–
depression connection: Evidence from a prospective longitudinal study. Personality and
Individual Differences, 54, 957-960. doi: 10.1016/j.paid.2013.01.002
Sherry, S. B., Richards, J. E., Sherry, D. L., & Stewart, S. H. (2014). Self-critical perfectionism
is a vulnerability factor for depression but not anxiety: A 12-month, 3-wave longitudinal
study. Journal of Research in Personality, 52, 1-5. doi: 10.1016/j.jrp.2014.05.004
Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Ecological momentary assessment. Annual
Review Clinical Psychology, 4, 1-32. doi: 10.1146/annurev.clinpsy.3.022806.091415
175
Shih, J. H., Abela, J. R., & Starrs, C. (2009). Cognitive and interpersonal predictors of stress
generation in children of affectively ill parents. Journal of Abnormal Child Psychology,
37, 195-208. doi: 10.1007/s10802-008-9267-z
Singer, J. A. (2013). Lost in translation? Finding the person in the emerging paradigm of clinical
science: Introduction to a special issue on personality psychology and psychotherapy.
Journal of Personality, 81, 511-514. doi: 10.1111/jopy.12017
Slaney, R. B., Rice, K. G., Mobley, M., Trippi, J., & Ashby, J. S. (2001). The revised almost
perfect scale. Measurement and Evaluation in Counseling and Development, 34, 130145.
Sliwinski, M. J., Almeida, D. M., Smyth, J., & Stawski, R. S. (2009). Intraindividual change and
variability in daily stress processes: Findings from two measurement-burst diary studies.
Psychology and Aging, 24, 828-840. doi: 10.1037/a0017925
Stoeber, J., & Otto, K. (2006). Positive conceptions of perfectionism: Approaches, evidence,
challenges. Personality and Social Psychology Review, 10, 295-319. doi:
10.1207/s15327957pspr1004_2
Suls, J., & Martin, R. (2005). The daily life of the garden-variety neurotic: Reactivity, stressor
exposure, mood spillover, and maladaptive coping. Journal of Personality, 73, 14851509. doi: 10.1111/j.1467-6494.2005.00356.x
Tong, E. M. W. (2010). Personality influences in appraisal–emotion relationships: The role of
neuroticism. Journal of Personality, 78, 393-417. doi: 10.1111/j.1467-6494.2010.00620.x
Vreeburg, S. A., Hoogendijk, W. J., Derijk, R. H., van Dyck, R., Smit, J. H., Zitman, F. G., &
Penninx, B. W. (2013). Salivary cortisol levels and the 2-year course of depressive and
176
anxiety disorders. Psychoneuroendocrinology, 38, 1494-1502. doi:
10.1016/j.psyneuen.2012.12.017
Vreeburg, S. A., Hoogendijk, W. J., van Pelt, J., Derijk, R. H., Verhagen, J. C., van Dyck, R., . . .
Penninx, B. W. (2009). Major depressive disorder and hypothalamic-pituitary-adrenal
axis activity: Results from a large cohort study. Archives of General Psychiatry, 66, 617626. doi: 10.1001/archgenpsychiatry.2009.50
Vrshek-Schallhorn, S., Doane, L. D., Mineka, S., Zinbarg, R. E., Craske, M. G., Adam, E. K.
(2013). The cortisol awakening response predicts major depression: Predictive stability
over a 4-year follow-up and effect of depression history. Psychological Medicine, 43,
483-493. doi: 10.1017/S0033291712001213
Watson, D., Clark, L. A., & Stasik, S. M. (2011). Emotions and the emotional disorders: A
quantitative hierarchical perspective. International Journal of Clinical and Health
Psychology, 11, 429-442.
Weissman, A. N., & Beck, A. T. (1978). Development and validation of the Dysfunctional
Attitude Scale: A preliminary investigation. Paper presented at the 62nd Annual Meeting
of the American Educational Research Association, Toronto, Ontario, Canada.
Wichers, M., Geschwind, N., Jacobs, N., Kenis, G., Peeters, F., Derom, C., . . . van Os, J. (2009).
Transition from stress sensitivity to a depressive state: Longitudinal twin study. The
British Journal of Psychiatry, 195, 498-503. doi: 10.1192/bjp.bp.108.056853
Wirtz, P. H., Elsenbruch, S., Emini, L., Rudisuli, K., Groessbauer, S., & Ehlert, U. (2007).
Perfectionism and the cortisol response to psychosocial stress in men. Psychosomatic
Medicine., 69, 249-255. doi: 10.1097/PSY.0b013e318042589e
177
Zuroff, D. C., & Blatt, S. J. (2002). Vicissitudes of life after the short-term treatment of
depression: Roles of stress, social support, and personality. Journal of Social and Clinical
Psychology, 21, 473-496. doi: 10.1521/jscp.21.5.473.22622
Zuroff, D. C., Kelly, A. C., Leybman, M. J., Blatt, S. J., & Wampold, B. E. (2010). Betweentherapist and within-therapist differences in the quality of the therapeutic relationship:
Effects on maladjustment and self-critical perfectionism. Journal of Clinical Psychology,
66, 681-697. doi: 10.1002/jclp.20683
Zuroff, D. C., Mongrain, M., & Santor, D. A. (2004). Conceptualizing and measuring personality
vulnerability to depression: Comment on Coyne and Whiffen (1995). Psychological
Bulletin, 130, 489-511; discussion 512-422. doi: 10.1037/0033-2909.130.3.489
Zuroff, D. C., Shahar, G., Blatt, S. J., Kelly, A. C., & Leybman, M. J. (2016). Predictors and
moderators of between-therapists and within-therapist differences in depressed
outpatients' experiences of the Rogerian conditions. Journal of Conseling Psychology, 63,
162-172. doi: 10.1037/cou0000139